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SWRCB,January 2002 — ./ Page f 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 for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: �c Q o m LS 4-( _Z Date of Testing: /0// o it i os— <br /> Facility <br /> sFacility Address: ZO 1/i'cfnf ac GO 6F <br /> Facility Contact: 44e q Phone: <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: 6�ttn ,, �h c- <br /> Technician Conducting Test: o, cj <br /> Credentials: aCSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: 4 License Number: 4flo f-3 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Comonent Pass Fail Not Repairs <br /> p <br /> Tested Made Tested Made <br /> ' (u -SI 7ye4,i, ❑ ❑ ❑ ❑ ❑ ❑ <br /> x' 24/ » ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> h( t 67 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> /Jnz d 1 9 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tl / ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> OC 1117 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UPC .31q z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> S4 tf / ®- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Shm / ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tin (< �l � C/1 >�" ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Jryu l r /ro S F n 4e i- /e—" 5e <br /> CERTIFICATION WTECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge., t ated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: Z <br />