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SWRCB, January 2002 . ! Page_of <br /> Secondary Containment Vesting Report Form <br /> ThiS form is intendedfor use by cont7-actorsperformi77gperiodic testing of USTsecondaty containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: v{Z -t- 'Fov Date of Testing: 5 676;7 <br /> Facility Address: p n'I A t e-f _ N EGArX5 6 <br /> Facility Contact: Phone: �p 2L _ S d <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: a047>A <br /> Technician Conducting Test: e L�m Mn <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. ense Number: p 7(, <br /> Manufacturer Trainin¢ <br /> Manufacturer Com onent s Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ D <br /> �Il s ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> 4S ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ o ❑ ❑ <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 TEST <br /> To the best of my knowledge J act, stated in this document are accurate and in full compliance with le requ emettts <br /> - - <br /> Technician's Signature �- - Date: <br />