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NRCR,January 2002 <br /> Secondary Containment Testing.Report Form <br /> his form is intended for zcsc by contractors performing periodic testing of UST secondary containment systems. Use the <br /> ppropriate pages of this form to report results for all components tested The completed form,written test procedures, and <br /> rintouts from tests(if applicable),should be provided to the focllity owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: —p <br /> Facility Address: <br /> Facility Cont<'�ct: ,a.ypr <br /> Phone: <br /> Date Local Agency Was Noti of Testing: Al / <br /> Name of Local Agency Inspector(ifpresent during tasting): <br /> 2. TESTINO'CONTRACTOR INFORMATION� . <br /> Cornnanv Name' <br /> Technician Conducting Test: ,[ ,/y* <br /> Credentials: 0 CSLB Licensed Contractor 51MCB Liccnscd Tank Tester <br /> License Type:• I License•Number: 'f //'�/ <br /> Manufacturer_TraininQ <br /> Manufacturer Component(s) Date Training Ex fres . <br /> I SUMMARY OF TEST RESULTS <br /> Not Repairs Component Pass Fail Not Repairs <br /> Component P )Foil Tested Mods <br /> Tasted Made <br /> c Q ❑ ❑ ❑ ❑ <br /> 'rQ 0 ❑ 0 ❑ <br /> 11pr r• rhe► <br /> 01 ❑ 1 ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> 0 0 0 ❑ <br /> ❑ 0 ❑ 0 <br /> 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 /> the best of my knowledge,the facts stated in this document are accurate and to full compliance with legal requirement, <br /> clinician's Signature:-4eDate: <br /> 2 'd 2110-13irL [1302] e22 %80 fr0 02 'idd <br />