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t <br /> SWRCB,January 2002 Page__L of <br /> Secondary Containment Testing Report Form <br /> This form is intended 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 /> printouts from tests (if applicable),should be provided to the facility ownerioperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Z Tate Testing: C1 A p <br /> Facility Address: / <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : 0j5-10,4 <br /> Name of Local Agency Inspector (if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: _ <br /> Technician Conducting Test: a l OCK <br /> Credentials: SLB Licensed Contractor SWRCB Licensed Tank TesterJc <br /> License Type: Q Aja f�-tQ g 6-10 License Number: Zo 5g�`D <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail' Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> x <br /> x <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICI^RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated i is re accurate and in full compliance with legal requirements <br /> Technician's Signature Date: q /D <br />