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SWRCB,January 2002 Page of �. <br /> x Secondary Contaonent Testing.Report Forn* <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: =6A-0 <br /> u r _,. Sl''1*Date of Testing: �' 65- <br /> Facility Address: _5C)p W , 1 d, 5(Z e N C N CAMP , �S <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: Oq 7,9 05 <br /> Name of Local Agency Inspector(rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION' <br /> Com an Name: ,4, <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type:. License Number: 6 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. <br /> SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> C, S /u— ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ 1 ❑ ❑ <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 knowledgefacts stated in this document are accurate and in full compliance with lega req (ements <br /> Technician's Signature: (`rn — i` "` - Date: <br />