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— <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> Thisform is intended fa 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 iestprocedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. <br /> FACILITY INFORMATION <br /> Facility Name: <br /> J Date of Testing: a <br /> rnPhone: <br /> Facility Address: 1`19L� 5• tea., r` — c,. <br /> Facility Contact: c9 S� Liu <br /> Date Local Agency Was Notified of Testing : z.Gl l I13 <br /> Name of Local Agency Inspector(ifpresent during testing): N <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: _T <br /> Technician Conducting Test: ( � D l� <br /> SLB Licensed Contractor RCB Licensed Tank Tester <br /> Credentials: <br /> License Number: <br /> License Type: S <br /> Manufacturer Training <br /> Manufacturer <br /> Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> A ❑ ❑ ❑ 11 ❑ ❑ El <br /> El <br /> n ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ El ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completio of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, t e facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: G� <br /> Technician's Signature: <br />