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SWRCB,January 2002 Page I of <br /> Secondary Containment Testing Report Form <br /> This form it intended for use by contractors performing periodic testing of UST secondary 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 13C At 011 Z I Date of?esting: <br /> Facility Address: �fl til- M 0.t✓t S MCA L4f C 6, Or- • 533 <br /> Facility Contact: I Phone: 20 9- 2j- 13YV <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t + '_ <br /> Technician Conducting Test: _ <br /> Credentials: 5L CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: Zr <br /> I License Number: &0'3 rD 7- <br /> Manufacturer Training - <br /> Manufacturer - Component(s) Date Training Expires <br /> y /J LeAK G OS <br /> 551/ fi✓ z`s' ic�iu7i9�' US/ <br /> eeltiv- ✓, I Z aJ <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs ' Component Pass Fail Not Repairs <br /> Component Pass Fail Tested Made P Tested Made <br /> 5 :/ b — 7r g-1 ❑ o ❑ 1 ❑ 1 ❑ o 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ o o ❑ ❑ <br /> ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ o <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> (t/� A� ✓>l�h/� t'l?-J4 <br /> CERTIFICATION OF TECHNICIAN'RESPONSIBLE FOR CONDUCTLTG THIS TESTING <br /> To the best of my knowledge,the facts stated in dds document are accurate and in full compliance with legal requirements <br /> Technician's Signature: LA24= !7 Date: 7 2 7 - O <br />