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SWRCB,January 2002 Page / of.-3 <br /> Seconds Containment 'Testing report Form <br /> Secondary b <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: Z04A° Date of Testing: — <br /> Facility Address: / <br /> Facility Contact: Phone: <br /> Date Local Agency Was Noti d of Testing: / / <br /> Name of Local Agency Inspector(rfpresent during testing: <br /> 2. TESTING'CONTRACTOR INFORMATION: <br /> Com an Name: <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor CB Licenwd Tank Tester <br /> License Type: Jill <br /> License Number: 9 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested Repairs <br /> r^"iponent Pass Fail Tested Made <br /> _ ❑ . ❑ ❑ ❑ <br /> 5 � ❑ ❑ ❑ ElAl . ❑ El 11 <br /> t <br /> n ❑ ❑ El ElEl ❑ El <br /> ate@ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> a ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: <br /> � Date: `� '� <br />