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CB January 2002 Page of <br /> SW-RCB, ry <br /> Secondary Containment Testing deport 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> s 1. Date of Testing: "c :, <br /> Facility Name: L,4 na Io, <br /> d <br /> Facility Address: 7 <br /> Facility Contact: E/ Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com any Name: —T;- <br /> Technician Conducting Test: /qp 1 b <br /> Credentials: D CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type:. License Number: / <br /> Manufacturer Training <br /> Manufacturer COM130--(sN Date Training Expires . <br /> 3. SUNEVURY OF'T'ES'T'RESULTS <br /> Not ERepairs Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Tested <br /> \ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 /> w <br /> Date: <br /> Technician's Signature: <br />