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Page of_ <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> Tlais form is intended fo-use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to repot results for all components tested. The completed form, written test procedures, and <br /> printouts fron tests(if applicable), should be provided to the facility o+,ner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> L/-,D Date of Testing: G <br /> Facility Name: <br /> 1 <br /> Facility Address: 5i 7 7 S S_ G'L _ <br /> S C _ Phone: CP--6 3 S` <br /> Facility Contact: c <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(ifpresent during testing): /VOA_ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> fCredentials: <br /> pany Name: i EN SYS �S <br /> nician Conducting Test: C/a' ��/o SWRCB Licensed Tank Tester <br /> SLB Licensed ContractorC License Number:nse Type: <br /> 1\9anuf2cturer Training Date Training Ex ires <br /> Manufacturer Coin onent(0 <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Not Repairs Component Pass Fail Tested Made <br /> Component Pass Fail Tested Made <br /> le FI ❑ Li ❑ ❑ ❑ ❑ ❑ <br /> - VA o,<- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Siaµ-c ��/ ❑ ° ° ❑ ❑ ❑ 0 <br /> 5 f C L/ c'i ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> (/� o ❑ D ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ a ❑ ❑ ❑ ❑ ❑ <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 knowledge, t facts stated in this docu ware ccurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br />