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WRCB MAY 2002 Page <br /> S �_of <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: r Date of Testing: <br /> Facility Address: ,S/ X <br /> Phone: _ <br /> Facility Contact: KC <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ACCU-TEST <br /> Technician Conducting Test: ELDON HATHAWAY 4.5.30 —Z ZR57- <br /> Credentials: ❑ CSLB Licensed Contractor RfSWRCB Licensed Tank Tester <br /> License Number: 1002 <br /> License Type: <br /> Manufacture Training <br /> Date Training Expires <br /> Manufacturer <br /> Component(sl <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Not Repairs Component Pass Fail Tested Made <br /> Component Pass Fail Tested Made <br /> ® ❑ ❑ ❑ W/ ❑ ❑ V ❑ <br /> �e z. ® ❑ ❑ ❑ 7r z-- ❑ ❑ A ❑ <br /> El R EJ <br /> r 0 z ❑ ❑ ❑ 1J0K_ 3-Y <br /> �r3 �' ❑ El ❑ (J c — 9 El El <br /> rhi�% •� ❑ � 1:1 El El El Ele- 7-9, <br /> ❑ El El El UC �o � ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ vas ��i1 Ell <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WATER WAS PROCESSED <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirzement}s. D <br /> DEC 2 6 2002 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br />