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15 <br /> SWRCB, MAY 2002 Page -L-_of <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: <br /> Date of Testing: - Q�Q-z- <br /> Facility Address: / SZ- <br /> Facility Contact: C'4 t.,q t Ao&n 0 7'Lj Phone:�Qq c�G7- ®30� <br /> Date Local Agency Was Notified of Testing: 6-'c:'-'- <br /> Name <br /> -'c:'-'-Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ACCU-TEST <br /> Technician Conducting Test: ELDON HATHAWAY <br /> Credentials: C3 CSLB Licensed Contractor J�fSWRCB Licensed Tank Tester <br /> License Type: License Number: 1002 <br /> Manufacture Training <br /> Manufacturer <br /> oCmaonent(sl Date Traini��Expires <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Not Repairs Cptn nent Pass Fad Tested Made <br /> Component Pass Fail Tested Made <br /> s [�. ❑ ❑ ❑ U m Z I ❑ ❑ ❑ <br /> El El <br /> u 3-� El El ❑ <br /> El <br /> -d2 ( " ❑ ❑ ❑ (J C Q ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ M[: <br /> ❑ ❑ El ❑ ❑ El <br /> ❑ 1:1 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done witter after compl tion gists: <br /> WATER WAS PROCESSED <br /> CERTIFICATION OF TECHNICIAN 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 />