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co,WRCB, January 2002 Page of <br /> Secondary Containment 'Testing Report Form <br /> T17is form is i77tended fol-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 /> /JJ P G�f G J Date of Testing: � ) 2—U <br /> Facility Name7 <br /> Facility Address: �j�Jv /�- C h/+, )!/ L J� fC -4 D6 <br /> Facility Contact: ✓k) 6 t 1 1 <br /> Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(7f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com anv Name: f� •''���� } � <br /> Technician Conducting Test: L.yJoS, -'J e-^ <br /> Credentials: ❑CSLB Licensed Contractor ;n- WRCB Licensed Tank Tester <br /> License Type: . License Number: i/L-(3 <br /> Manufacturer Training <br /> Manufacturer <br /> Com onent s Date Training Expires . <br /> 3. SUTv1iTvLA-R Y OF TEST RLS?JLTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> p Tested Made <br /> C ---------- <br /> 7Z ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 /> Date: '' o <br /> Technicians Signature: <br />