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WSWRCB.January 2002 Page of <br /> Second� Containment Testing ReportForm <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this forms 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 ownerloperator for submittal to the local regulatory agenev. <br /> 1. FACMW INFORMATION <br /> Facility Name: 4,e - �• ,� Date of Testing: Z2 <br /> Facility Address: a 7 F Z"7J, C -5 <br /> Facility Contact Q t l fi t'yr Phane: o <br /> Date Local Agency Was Notified of Testing Gy <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESUNG CONTRACTOR]INFORMATION <br /> Company Name: <br /> Technician Conducting Test: G �- ✓ a G� h' <br /> Credentials: 0 CSLB Licensed Contractor ffSWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> ManufacWmr C ei*s Date Training EVres <br /> 3. SUMNLARY OF`PEST RESULTS <br /> Component Plan Failepairs <br /> i Not .rs ested r Component Pass Fail Tested <br /> Nude <br /> El El 0 11 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ u <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ "❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water ager completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts Mated in this document are accurate and in full compliance with legal requirements <br /> a <br /> Technician's Signature: Date; <br />