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Page of <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> ms. Usethe <br /> This form is intended.fh?suse <br /> nrm to contractors <br /> resulisrfor oil orm components periodic nesteding .The complete UST f rmtawrmeen test procedures, and <br /> appropriate pages oft f P <br /> printoutsfrom tests (if applicable),should be provided to the.facility ownerloperatorfor submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> atate of esting:/— <br /> FFacility <br /> cili Name: • ; ��,, <br /> cility Address: phone: <br /> Contact:te Local Agency Was Notified of Testing: <br /> 110 / - <br /> Name of Local Agency Inspector(ifpresent during resting): � Orv-P <br /> 2. TESTING CONTRACTOR INFORMATION <br /> T s t <br /> Ecledentials: <br /> Name: DN <br /> n Conducting Test: I�SWRCB Licensed Tank Tester <br /> yerCSLB Licensed Contractor License Number: <br /> ype: <br /> C /0 S <br /> 14 Manufaeturer Training Date Trainin Ex ires <br /> Manu acturer <br /> Com onent(s <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Not Repairs Component Paas Fail Tested Made <br /> Component Pass Fail Tested Made <br /> ❑ ❑ ❑ Cl <br /> e ❑ ❑ ❑ ° ❑ ❑ ° <br /> vc ❑ ❑ ❑ <br /> Li U <br /> 0 0 ❑ ❑ <br /> ❑ ❑ O O <br /> ❑ ❑ D 0 0 ❑ D ❑ <br /> p 0 ❑ 0 ❑ ❑ ❑ D <br /> 0 D ❑ ❑ 10 D ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: 1 <br /> U <br /> CERTIFICATION OF <br /> TECHNICIAN <br /> OCONDUCTING <br /> ODUCIN THIS TESTING r <br /> To the best of MY knowledge,t addocument u ain legal requirements nts <br /> Technician's Signature: Date: <br />