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RECEIVEL <br /> 'i <br /> SWRCB,January 2002 Page of <br /> Secondary Co tain>r ien eosti.ng Report Form <br /> This form is intended for use by contractors perfor secondary containment systems. Ilse the <br /> appropriatepages of this form to report results far all Uftpb rgrm completedform,written testprocedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the'local regulatmy agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: �' 2 0 gle. Date of Testing:g Z r/�''^-t S <br /> Facility Address: t,y 9 � <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 7;U 1, ;1'5 <br /> Name of Local Agency Inspector{ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Peny,Inc <br /> Technician Conducting Test: NI e 1,9 ;' ICC# /S' ;7 3 f'' <br /> Credentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,c10,C21/D40 flaz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Futmished U on Request <br /> 3. SUMMARY OF TEST M f LILTS <br /> Component Pass Fait Not Repairs Component Pass Fail Not Repairs <br /> > Tested Made Tested Made <br /> 7 . R] ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9l [ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> _jEE❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 'Z ~/X <br />