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S-WRCB,January 2002 Page f of <br /> b 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(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: P / *11 1W,4 `T Date of Testing: i5 D <br /> Facility Address: S// PA 0 -7 <br /> Facility Contact: Fu 56- - Phone: (� ?) 4-73 -11,7,7 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION: <br /> Com an Name: 6-T <br /> Technician Conducting Test: t,4 <br /> Credentials: 0 CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type:. License:Number: o 4 7 <br /> 111 �g Manufacturer Training <br /> Manufacturer Com onerrt s Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> U7. <br /> p Not Repairs <br /> Component Pass Fail Tested Not Repairs <br /> Component Pass Fail Tested Made <br /> r t teen e b v 11 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> l ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 /> Date: O 23 1 0 <br /> Technician's Signature: <br /> `� <br />