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SWRCB,January 2002 Page I of 'p- <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7Z P A R&o Date of Testing: fJG <br /> Facility Address: S"' F' <br /> Facility Contact: "5, Phone: _ -V`-- <br /> Date Local Agency Was Notified of Testing: / 5 l jrl- <br /> Name of Local Agency Inspector(if present during testing: _ S k A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: 02 ; <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: $gI;LA146-10 License Number: J '0,7,f" <br /> Manufacturer Trainine <br /> Manufacturer Co onen s Date Trainigg Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fall Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> F/trt� <br /> (s^�/41�d <br /> I F/4c..- <br /> 9 !� <br /> EJ <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,th facts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:-��/�� <br />