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S WRCB,January 2002 Page_of_ <br /> 1 Secondary Contalnent Testing Report Form <br /> This form is 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 lest 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: Y zA —ttDate of Testing: 6 �� <br /> Facility Address: �4 N \ W "l CG <br /> Facility Contact: Sn \Ij 7 <br /> Date Local Agency Was otified of Testing <br /> Name of Local Agency Inspector(rfpresen(during tes ' g): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: 1 PN\m <br /> Credentials: ❑CSLB Licens6d Contractor XSWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Trainin¢ <br /> Manufacturer Comm s Date Training Expires . <br /> s. SMvU A!Vj( OF TEST RESITTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> 1 c e� X ❑ ❑ ❑ ❑ <br /> }� x ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> L S f--tntJ <br /> CERTIFICATION OF TECRNICLAN 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; Z,9/Ltel . Date: <br />