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e,w <br /> page I of S <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors perfenning periodic testing of USTsecondary containment systems. Use the appropriate pages of <br /> this form to report results for all components tosted, The completed form, written test procedures, and printouts from t©sts(if applicable),should <br /> be provided to the facility ownerloperetor for submittal to the iocai regulatory agency. <br /> .®.�.. 9. FACILITY INFORMATION <br /> Facility Name' Dale of Testinr��- - <br /> Facility Address; <br /> Facility Contact. _ Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspactor(i(present during testing); <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name' EPIC Compliance System <br /> Technician Conducting Test: <br /> _ Credentials: 2 ( Licensed Contractor LL,SWRC5 Licensed Tank Tester <br /> License Type; A License Number:880430 <br /> per.•: '�y, jj"�..�•--'•wro.;i"r r, io. , ��T,''�is� + W. <br /> Manufacturer Training <br /> Manufacturer_ Componeni�s� Date Trainin 1~x ires <br /> __....._. ...,.._..._..........._......... ...._..,. .,. ......,_ �,.;..._., . __�._._.. .._..._..._... _.__... d <br /> 3, SUM ........ <br /> r Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Pail <br /> Tested Made Tested Made <br /> tn D <br /> , <br /> ...- ' <br /> .._._..__._._.�...._�...,. ..._�..�_... .... .Fi t t t� t� 13 <br /> C, ! a i7 r 171I <br /> r:1 t E.1 <br /> j...I <br /> If hydrostatic la,ti,q,vS performed,describe what was done MIM tile,w£jter after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the fag stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: :� :� .-•- <br /> TT/60 39tid 71IH >IOIlHO EZ5££6£T99 89:80 60OZ/Vo/zo <br />