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SWRCB, January 2002 Page I of 1 <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 />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 />Facility Name: 151 4 C% 4-<,l I Date of Testing: 7 7�6) <br />Facility Address: 1.CA.i .�..� e i4ti1.,.y c� i ,L Z. <br />Facility Contact: v -t sic Phone: ZO 17 33Y-01+'']$ <br />Date Local Agency Was Notified of Testing: -7 5 66 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R i } w- } Nan.C.'a -j'C S -R 4 .- <br />Technician Conducting Test:-Cj"Q-W`CLWEV I F t e.r(A Ty' <br />Credentials: C CSLB Licensed Contractor WRCB Licensed Tank Tester <br />License Type: i"ec K I t, eae, c.y/ License Number: 10— 11-2-6 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass Fail <br />Tested <br />Not <br />Repairs <br />Made <br />Component <br />Pass Fail <br />Not <br />Tested <br />Repairs <br />Made <br />,-In <br />❑ <br />❑ <br />❑ <br />I <br />S <br />❑ <br />❑ <br />❑ <br />F titEe�/Y7r"ut1G � <br />❑ <br />❑ <br />❑ <br />LAD 60 1 £ 2.. <br />❑ <br />❑ <br />❑ <br />WMIOV <kmz V3 <br />❑ <br />❑ <br />❑ <br />lel 06-03f q <br />❑ <br />❑ <br />❑ <br /><fg r �t -: <br />❑ <br />❑ <br />❑ <br />� �J !C i'a <br />6/41,(()x�' <br />El <br />11 <br />L-1 <br />j <br />[� <br />El <br />El <br />111/` <br />��Gl/l <br />61 .. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />r 0 12- -I <br />El <br />[1it <br />J >i ';• , .' J'.. Ew ' r s 'y" i <br />❑ <br />❑ <br />❑ <br />} <br />! l P p/ i ddb <br />LlQ <br />E� <br />/ <br />y�j <br />El <br />! <br />❑ <br />❑ <br />❑ <br />❑ IJ <br />❑ <br />If hydrostatic testing was'performed, describe what was done with the water after completion of tests: <br />N� ..f_ ,- At, i ,;J J :1 <br />� l l� ;f Q. ✓ ,e' ; � • `� 'tel / � g} � �s% va°'" 9? / .� ;',� �-t C' 6,, ' �'� ;, > .rl�� '"v <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In this document a�"cc gyrate and in full compliance with legal requirements <br />f ,:, <br />Technician's Signature: G-+ ,..:w-- . ,.' �..,.• �.,.. Date: 7 <br />