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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> .This fore: is intended for use by contractors performing periodic testing of LIST 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: — <br /> Facility Address: '3®3 � � �✓ <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: – 1--� ' <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING*CONTRACTOR INFORMATION: <br /> Com an Name: <br /> Technician Conducting Test: M <br /> Credentials: ❑CSLB Licensed do6tractor R-Licensed Tank Tester <br /> License Type:. License.Number: <br /> III Manufacturer Trggkg <br /> Manufacturer Cam onent s Date Training Expires . <br /> 3. SUNEMLARY OF TEST RESIT <br /> ' Repairs Not Repairs <br /> Not <br /> Component Pass Fail 'fNot Made Component Pass Fail Tested Made <br /> estel- 0 i®G� 14 ❑ . ❑ ❑ ❑ <br /> 11f ❑ ❑ ❑ ❑ <br /> F ❑ ❑ ❑ ❑ <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 knowledge,the facts state44n this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technicians Signature- <br /> C <br /> µ <br />