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MCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printoulsfrom tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency <br /> 1. FACILITY INFORMATION <br /> Facility Name: P 6,0 .t1 O5`9 s— Date of Testing: <br /> Facility Address: (r;bt ,V c <br /> Facility Contact: S c /� Phone: c <br /> Date Local Agency Was Notified of Testing: H12,1- <br /> Name <br /> S r io <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Couipany Name: %4 / <br /> Technician Conducting Test: f / 6 D C. <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: S L//f Z j C - iQ License Number: 37pl - O 9 <br /> M112tifeetnrer Training <br /> Manufacturer Co nen s Date Training Expires <br /> PLZ <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 7 J / I Itj X111?6 f <br /> p 114S7E'le /=/LL <br /> /=/LG <br /> 1 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Z �G i �`' ✓"5 %tom %/� 7- <br /> CERTIFICATION <br /> CERTIFICATION OF TECEMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technrcian's Signature: ��'Ci z�%%` `�' Date: <br />