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Secondary Contai ent Testing Report Forillm <br />This form is intended for use by contrac performing periodic testing of UST secondTcontainment 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 INFO TION <br />Facility Name: -r Date of Testing: (o <br />Facility Address: ` F -2-t <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: a° I oce <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING' CONTRACTOR INFORMATION:` <br />1*061taAW "A M-11 <br />Component Pass Fail Not Repairs Component <br />Tested Made <br />Pass <br />Fail <br />Not <br />Not <br />Repairs <br />Made <br />.591 U- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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 knowledb e, the facq stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signatu �'"� Date: <br />