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SVaCB, January 2002 <br />Secondary Containment Testing Report Form ' MAY 142003 <br />This form is intendedjor use by contractorsperformingperioaVc testing of Wsecondwy containment sj* <br />�,qp. �� e the <br />appropriate pages of this form to report results far all components tested Me completed form, written testp , I• t,�4-oqt <br />.: <br />printouts from tests ('applicable), should be provided to the facility ownerloperatorfor submittal to the Iota <br />1. FACILITY INFORMATION <br />Facility Name: - I Date of Testing: <br />Facility Address: r 6'0 C' <br />Facility Contact: <br />C\ <br />0 Z CL Phone: ;Zr <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: CV-, a=gn S;�, nf--, -P'e <br />Not I <br />Teswd I <br />Technician Conducting Test: <br />Pass <br />Credentials: X, CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: DL\p <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) Date Training Expires <br />0, <br />El <br />❑ <br />El <br />11 <br />11 <br />3. SUMMARY OF TEST RESULTS <br />Component Pass Fail <br />.7 <br />Not I <br />Teswd I <br />Repairs Component <br />Made Component <br />Pass <br />Fail <br />Not <br />Repairs <br />Made <br />0, <br />El <br />❑ <br />El <br />11 <br />11 <br />2- 7, 0 <br />o <br />0 <br />0 <br />0 <br />0 <br />11 <br />12 4C --,PF 3 4- 0 <br />0 <br />0 <br />74 7 Yo <br />0 <br />El <br />(t 114 1.21 <br />El <br />0 <br />L7 <br />11 0 <br />0 <br />0 <br />If hvdrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTMCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts s,wed in this document are accurate and in full compliance with legal requirements <br />r*d",N I — 5�- <br />Technician's S .: �1 Date- <br />