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.SWRCB, January 2002 Page / of <br /> Secondary Containment Testing Deport Form <br /> This form is intendedfor use by contractors performing periodic testing of USTsecondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completedform, 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 /> FacilityName: G of ; Date of Testing: �C� �p <br /> Facility Address: 3 S R P&Af E <br /> Facility Contact: E� Phone: CaC�1) 33 �1 <br /> Date Local Agency Was !Notified of Testing : 10 • /Z ' 0 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Companv Name: nr <br /> Technician Conducting Test: N i rnrvlo Fe,,IiV <br /> Credentials: ❑ CSLB Licensed Contractor SWRCR Licensed Tank Tester <br /> License Type:. License Numoer: (o9 a <br /> Manufacturer Training <br /> Manufacturer <br /> Com onent s) Date TraininL Ex fires . <br /> 3. ST.7TvEMARY OF TEST RESULTS Not Repairs <br /> Pass Fail <br /> Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 knowleri;e, lY� acts Ills document are accurate and in full compliance with legal requirements <br /> Date:4b7L <br /> Technician's Signature: <br />