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SWRCB, January 2002 2, Page of <br /> Secondary Containment TeSting'Report Form <br /> This fora: is intendedfor use by contractors performing periodic testing of UST secondmy 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: W1,c,�—� Date of Testing: 3 Q <br /> A►J-r�c�w. � x�2�ys <br /> Facility Address: "6144-3"F,Z� <br /> nQ/W -57- <br /> Facility Contact: Phone: on <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTINGCONTRACTOR INFORMATION <br /> Com any Name: rFo, — --T—e--,-T <br /> Technician Conducting Test: NE 1 ✓vi m U <br /> Credentials: ❑CSLB Licensed Contractor VSWRCB Licensed Tank Tester <br /> License Type:. License Number: D q- A? <br /> Manufacturer Training <br /> Manufacturer <br /> Com onent s Date Training Expires . <br /> 3. SLTrvE ARY OF TEST RESULTS <br /> Not Repairs Pass Fail Not Repairs <br /> Component Pass Fail Component Tested Made <br /> p 7^ested Made <br /> S�t s��w Y ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> q ap►ty x ❑ ❑ ❑ ❑ <br /> ids t.� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ El <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TEC ICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowled;e,the a t stat d in this docunten!are accurate and in full compliance with legal requirement/s <br /> Date: <br /> Technician's Signature,:,/,"' t <br />