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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors perforating periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components testees'. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility ouvner operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:4/L,`�/� ."c' 'c G'G.^� �? r�"�^G Date of Testing: — <br /> Facility Address: /GAG' / 5C7b° lirb�' T< <br /> c <br /> Facility Contact: ,�.� i Phone: , C — -7 <br /> Date Local Agency Was Notified of Testing : 2/ -p2_ <br /> Name of Local Agency Inspector(if present during testing): �--(C7 <br /> 2. TESTLNG CONTRACTOR INFORMATION <br /> Company Name: C/V-� ', o S cam'. c`c 12 � <br /> Technician Conducting Test: <br /> Credentials: A CSLn Licensed Conitauioi <br /> SWFtC,fs Licensed Taal:Tester <br /> License Type: 7)L L` RD License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUiNUN-1ARY OF TEST RESULTS <br /> Component Pass Fail ltiot Repairs Not Repairs <br /> P Component I Pass Fail Tested <br /> Tested Made Made <br /> c <br /> 5jr - 1 � r ❑ I ❑ ❑ ❑ ❑ <br /> 51/ �- I I i i ❑ I r_ I ❑ ❑ <br /> 94/1V G/1—chi" 1 ❑=111 ❑ n ( !� n <br /> :�" �:-vim � # _ _ I ❑ _i ❑ ❑ <br /> �,. — ❑ ❑ <br /> ❑ ❑ ) ❑ ❑ <br /> 2 I _ ❑ i ❑ <br /> 1�L' — _ ❑ ❑ ILl ❑ G <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> H <br /> = - <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance urith legal requirements <br /> Technician's Signature: r� <br /> .. Date: <br />