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page_01 <br /> SWRCB, January 2002 . <br /> Secondary Containrwt Vesting Report Form <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment systenss. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts <br /> appropriate <br /> tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION Date of Testing: O <br /> Facility Name: h(c J � ft <br /> �Aq�/Qoh , �l -�-1 7 <br /> Facility Address: C)0 1t� Fnone:(AL-q) <br /> Facility Contact: e5`� <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector (rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: e '� <br /> Technician Conducting Test: 11� i rr rn O SWRCB Licensed Tank Tester <br /> Credentials: ❑CSLB Licensed Contractor License Number: pc{ (p <br /> License Type:. <br /> Manufacturer Training Date Training Expires . <br /> component(s) <br /> Manufacturer <br /> 3. 5UIvIlVIARY ®F TEST RESULTS Not Repairs <br /> Not Repairs Component Pass Fail Tested Made <br /> Component Pass Fail Tested Made ❑ <br /> ❑ ❑ ❑ <br /> ❑ El 11El <br /> Sup ❑ ❑ ❑ <br /> 2 0 ❑ ❑ ❑ ❑ <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,tlae facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: 2 t <br /> Technician's Signature:>s <br /> V <br />