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__ -- <br /> • Page_o <br /> SWRCB, January 2002 <br /> Secondary Containment Testing Report Form <br /> econdmy containment systems. Use the <br /> ,This farm is intended for use by contractors performing periodic testing of UST sen test procedures, and <br /> orm to report results for all components tested. The completed form, writt <br /> appropriate pages of th s f <br /> printouts from tests(f applicable), INFORMATION be provided to the facility° erator for submittal to the local+•egu atory ages <br /> ATION <br /> I. FACILITY Date of Testing: n—" <br /> Facility Name: r� r. �✓ ' f <br /> Facility Address: ' :9 Phone: i T r�1� —0 � <br /> Facility Contact: �Y ee <br /> Date Local Agency Was'Notified of Testing'during testing)' <br /> Name of Local Agency Inspector(fp <br /> CONTRACTOR INFORMATION: <br /> 2. sen <br /> TESTING CONTRA <br /> Com anv Name: <br /> r, ®$WItCB Licensed Tank Tester <br /> Technician Conducting Test:, r/f�P � I f VM�0 y_J <br /> Credentials: ❑CSLB Licensed Contractor License Number: i <br /> License Type: Manufacturer Training Date Training Ex ire' . <br /> Com onent s <br /> Manufacturer <br /> ri GF TEST p PSULTS Not Repairs <br /> 3. SV1l aI'e Repairs Pass Fail Tested Made <br /> Not p Component <br /> Component <br /> Pass Fail Tested Made ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> tt 1 <br /> 5 , l./ ❑ ❑ ❑ ❑ <br /> r ❑ ❑ ❑ ❑ <br /> s ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ Cl ❑ ❑ <br /> ❑ Cl ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> performed,describe what was done with the water after completion of tests: <br /> If hydrostatic testing was , f <br /> Pl <br /> RE <br /> CERTIFICATION OF TECHNICIAN <br /> SPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this <br /> document are accurate and in full compliance with legalr�e2en s <br /> Date: <br /> Technician's Signature: <br />