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e <br /> SWRCB,January 2002 Page—L—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 far 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 /> Facili Name: t(- Z1 '0 ?_,1,3 Date of Testing: J <br /> Facility Address: 22.06 .ti jL $�— <br /> Facility Contact: h51C <br /> 4&JL.... Phone: xv <br /> I---- <br /> Date Local Agency Was Notified of Testing: ,& A <br /> Name of Local Agency Inspector(if present during testing): M. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Co any Name: <br /> Technician Conducting Test: (� G <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A A-58 14*7-,6 C—/U License Number: �49 <br /> Manufacturer Training <br /> Manufacturer Co nen s Date TrajniM Ex fres <br /> . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91 <br /> S r1� <br /> k V <br /> F <br /> c t <br /> � w✓ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> a$IF <br /> d�sheer•' T,�f-T <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: /2S <br />