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SWRCB, January 2002 Page / of <br /> Secondary Contain. .:nt Testing Deport Form <br /> This fornz is intended for-use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this fornz 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 /> r <br /> Facility Name: �'.A {--`!�, v( �,, i Date of Testing: ICS �O <br /> � � 7 �GC`. �. <br /> Facility Address: �`� S <br /> Facility Contact: r._,� a"� Phone: (;LC I j 3 j�' -1�i <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> company Name: -PPnrr\rs <br /> Technician Conducting Test: �'D r N, i rn rn o r 7'`, L2b <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: . License.Number: L <br /> 9 1 10 <br /> Manufacturer Training <br /> Manufacturer <br /> Component(s) Date Training Expires . <br /> 3. SUTvfi AARY OF 'PEST RESULTS <br /> Not Repairs Pass Fail Not Repairs <br /> Component Pass Fail Component Tested Made <br /> Com <br /> p Tested Made <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> El El <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 knXthete. his docunzent are accrz`rate and in fizl!compliance with legal requirements <br /> Technician's Signatu <br /> Date: /b <br />