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SWRCB,January 2002 <br /> Page_of <br /> Secondary Containment 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 far 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: —�- G Date of Testing: — I - <br /> Facility Address: Z r00 r <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: r <br /> Technician Conducting Test: -r <br /> Credentials: 5 CSLB Licensed Contractor SWRCS Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainin <br /> Manufacturer Com onent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Not Repairs Not Re <br /> p Pass Fail Tested Made Component Pass Fail pairs <br /> �y Tested Made <br /> S cc r / L t rt 1t ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C + hem GY ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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,the facts state in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 2- 1 ` U <br />