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� n <br /> Page_�L Of <br /> SWRCB, MAY 2002 <br /> FINAL DRAFT <br /> Secondary Containment est' a -- <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> . FACILITY <br /> Date of Testing: /� <br /> Facility Name: C oo! i �r <br /> Facility Address: y,$ / ,2. / .S [� 1.5.?®7 <br /> Phone: ® q' e-17 7 <br /> Facility Contact: y eC <br /> Date Local Agency Was Notified of Testing: Zf l 0—Q <br /> Name of Local Agency Inspector(if present during testing): <br /> CCU_ est <br /> 2. TESTING CONTRACTOR INFO ON ANDREW DRIVE <br /> Company Name: ACCU-TEST Vein <br /> 1 <br /> Technician Conducting Test: ELDON HATHAWAY -T3 0 <br /> Credentials: r SWRCB Licensed Tank Tester <br /> License Number: 1002 <br /> License Type: <br /> Manufacture Trainine Co <br /> Manufacturer <br /> ComvonenKst Date !i n'ncpires <br /> ai <br /> 3. SU OF TEST SULTS <br /> Not Repairs Pass Fail Not Repairs <br /> Component Pass Fats Tested Made Component Tested Made <br /> El D <br /> rS' z ❑ ❑ ❑ LJQ G _ ❑ ❑ <br /> ❑ 11 ❑ 11 U c ❑ ❑ ❑ <br /> ❑ ❑ 11 El f-1 El El <br /> .d ❑ ❑ ❑ El 11 Ela e ❑ El <br /> ElF1 F1 ❑ ❑ <br /> 0 F1 El 0 <br /> ® ® ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> c �r /` ❑ ❑ ❑ El El 1:1 <br /> ❑ ❑ ❑ ED <br /> If hydrostatic testing was performed,describe what was done wi a water after compl f s: <br /> ion o <br /> WATER WAS PROCESSED <br /> CERTIFICATION OF TECHNICL4,N 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 />