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° u.. <br /> SWRCB,January2002 Page NED <br /> Secondary Containment Testing Report Form AUG 2 2 2003 <br /> This form is intended for use.by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthisform to report resultsfor all components tested. The completedform,written testprocedures;and .t,"^lJC6u}IpN cnr.,r�r <br /> printouts frons tests(f applicable);should be provided to thefaciliry ovmer/operatorforsubmitial to the local regulatory dFW01`MERGEND JERVICE <br /> 1. FACILITY INFORMATION <br /> Facility Name: jj L, Date of Testing: 03 <br /> Facility Address: `{�D S <br /> Facility Contact: P, Phone: Q <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: �S <br /> Technician Conducting Test: t'— <br /> Credentials: ll1,CSL.11 Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: tt;- A L License Number: gD� <br /> Manufacturer Trainins, <br /> Com onent(s Date Trainin x fires i <br /> Manufacturer <br /> l, -Orct <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Component Pass Fall Tested Made <br /> Tested Made <br /> (�✓8 rl I & ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: b <br /> f W 4S O <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowl!,:k <br /> e,th facts stated in this doctanent are accurate.and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: ` ' <br />