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S WRCB, January 2002 . • Page_of_ <br /> Secondary Containment Testing Report Form <br /> r This fornt is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report results for all components tested. The completedform, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 2 (a t Date of Testing: —/3 —0�} <br /> Facility Address: <br /> Facility Contact: T,-e-e Phone: (2-06,E) <br /> Date Local Agency Was Notified of Testing: . <br /> Name of Local Agency Inspector fit present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com anv Name: <br /> Technician Conducting Test: ,I ,p <br /> Credentials: ❑CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type:. <br /> License;Numbet: <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUTvil�Itu�Y CF TEST' P.ESTJLTS <br /> Not Repairs Pass Fail Not Repairs <br /> Component Tested Made <br /> Pass Fail Component Tested Made <br /> !�. ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: CA Date: `� <br />