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0 0 <br />SWRC8, January 2002 Page � of <br />Secondary Containment Testing Report Form <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: Date of Testing: 0,— <br />Facility Address: <br />Facility Contact: Phone " <br />Date Local Agency Was Notified of Testing: t / <br />Name of Local Agency Inspector (if present during testing): - <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Champion Precision Testing, Inc. <br />Technician Conducting Test: Service Technician# <br />5Q4 10?1Q1ka- 07 <br />Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: D-40 License Number: 848150 <br />Manufacturer Training <br />Manufacturer Coni onent(s) Date Training Expires <br />SUMMARY3. OF <br />Component <br />TES' <br />1 <br />o�r��■ <br />�000 <br />n®®o <br />�� <br />►: o0o <br />aor•�o <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 fads stated in this document are accurate and in fullcompliance with legal requirements <br />Technician's Signature:(-_ _ Dater <br />r <br />