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SWRCB. January 2002 Page of� Secondary Containment Testing Report Form 7his.1brin is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts Urotn tests (if applicable), should be provided to the, facility owner/operator, for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: I Date of Testing: T, 5- Address: -Facility Facility Contact:hone: Repairs Made Date Local Agency Was Notified of Testing: t '" Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Champion Precision Testing, Inc. Technician Conducting Test: { Service Technician# Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: D-40 License Number: 848150 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made El El 11 1.1 ❑ ❑ ❑ [I ❑ ❑ ❑ `. a 314 El ElElLl❑ LJ ❑ ° ❑ ❑ ❑ ❑ [1 I 1 ❑ 0 El 11 0 Cl ❑ ❑ ❑ L_I ;:I II ❑ ❑ ❑ ❑ ❑ !:J Ll Il 0 ❑ ❑ ❑ ❑ I1 iI II t] ❑ ❑ ❑ ❑ L.l II U ❑ D_ r-1 ❑ ❑ ❑ L.:I I_J ❑ ❑ ❑ ❑ ❑ L', III ❑ ❑ ❑ ❑ CI !.I II C! If hydrostatic testing was performed, describe what was done withthewater after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of nq knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature -- if� Date: