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SWRCRJanuary 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 I FO TIO <br /> Facility Name: wck <br /> , Date of Testing: <br /> Facility.Address: In <br /> Facility Contact: L Phone: -- <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during to ting): I <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Conducting Test: Service Technician# LTC <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 /> 3. SUMMARY OF TEST RESULTS <br /> Pass <br /> Not Re airs Component Fail Not Repairs <br /> Component Pass Fail Tested Made PTested Made <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ D ❑ ❑ ED ❑ <br /> c ❑ 1L El11 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pt v® t.�sar�`4'A \:>qc <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 full compliance with legal requirements <br /> 2J <br /> Dater <br /> Technician's Signature: L <br />