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SWRCB, January 2002 rage t or <br /> • Secondary Contair '-Int Testing Report Form <br /> This form is intendedfor 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ( _ n P� Date of Testing: M tA <br /> Facility Address: <br /> Facility Contact:FjU� �, Phone: V`%) ct 3 3 --7Uy CO <br /> Date Local Agency Was Notified of Testing : 2 110 b Oh <br /> Name of Local Agency Inspector(rfpresent during testing): a v) <br /> 2. TESTING CONTRACTOR INFORMATION; <br /> Com anv Name: T v fl- <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor cgSWRCB Licensed Tank Tester <br /> License Type:. License,Number:�!% <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Ex ires . <br /> 3. SUNEV AIZY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> p Tested Made <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 ilre best of my knorpled,e, the facts stated in this document are accurate and in full compliance with legal requirements <br /> 7� r Date: <br /> Technician's Signature: <br />