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I <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is iniended.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 /> prinioutsfi•om tests(if applicable),should be provided to the.faciliry owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: v P Ar 6 3/2 Date of Testing: <br /> Facility Address: ( p o S e <br /> Facility Contact: ph N SCPhone:ZD _ 60 - 3 3 3S <br /> Date Local Agency Was Notified of Testing : ZI <br /> Name of Local Agency Inspector(ifpresent during testing): p�v,(? <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 7 � t <br /> Technician Conducting Test: J2,p 6C7"l— 7491��J <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: 5 Z G�r� License Number: �/ <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> D✓YI�r'X <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Tested Made <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> uo ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ 0 <br /> F Cl ❑ ❑ ❑ ❑ ❑ ❑ <br /> 37 4 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El 11 11 ❑ El 11 ❑ <br /> ❑ El El ❑ ❑ El ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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 requirements <br /> Technician's Signature: ��`i G� 7 Date: <br />