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�. January 2002 <br />Page _._ . _ . of . <br />Secondary Contair> ment Testing Report Form <br />for)n is intendedfor use by ct)rltractols perfi)rmirlg periodic testing of (JS7'second1ry ct)ntnlr/7ttertt systems• Use <br />,)ropriate pages of'tllis form to report results for all components testea! The completed fvrrre, 11,jtter4 test procetturesh anti! <br />,rintouts from tests (i/ applicable), should be provided to tine facility ojvrlerioperator for submittal to the !Deal regllllrty, trg� nry. <br />I. FAC11,11Y 1NFORAMTION <br />Facility Name: Facility Address: — <br />Date of Testing: <br />� � _— .` <br />Facility <br />_._._ Phone: <br />1?ate f.uc al Agency Was Notifc ci of�TestZngi:,r,/'� <br />g y pector (P/ present llurtrf testtrf --`�- -- <br />2. TESTING CONTiZACT Ol"t INFOR TION _. ._ . �_ <br />Cot�cparry Natue: CharttpiOil Precision Testing, Inc. <br />Technician Conducting Test: ; - - --_ <br />_ __---L- __I__ ® <br />Credetrtiais: X CSLB Licensed Contractor"-`=---- <br />_ ----- ___ l7 S CB Licensed Tank <br />"Tester <br />License Number: $0459(3 - - - -----_ <br />1Vlanufstcturer Trai�wu� r. <br />Manufacturer <br />Coal polie rii(s) <br />!)ate Trair►il! Expires <br />3. SUMMARY OF TEST SULTS <br />Component!rasa Fail Not Repairs <br />—___ _ _-•- Tested Made Component Pass Fait Not Repairs <br />Tested Made <br />❑ ❑ I_i <br />❑ ❑ <br />❑ ❑ ❑ r:� <br />CJ - --_ _ ❑ L7 CJ <br />Cl ElL7 ri . !-� <br />- — - CI l7 CJ ❑ <br />Ll L1 <br />_ ��_ , ,�� �__ IBJ ❑ � ___._.-..__________ ❑ 1A <br />-7- ,--- 6�t ❑ _ L7 IJ _ i l ❑ CJ ❑ <br />T hydrostatic testin was > <br />g perfor ttted d� scrdx what was done with the water after completion of tests: - <br />CERTIFICATION OF TECHNICIAN of my RESpONSIi3LE FOR CONDUCTING THIS TESTING <br />a the best kno►tledge, thefac is stinted 1n thls clocrnreaeru are 4wurate and lea full co»apliatwe Jsft legal requirements <br />a� 9 <br />eclrtyician's Signaicrre: <br />- Date:J <br />