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SWRCB,January 2002 Page f 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: <br /> Facility Address: G( <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: toklog <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:-1 <br /> Technician Conducting Test: <br /> Credentials: O CSLB Licensed Contractor AlSWRCB Licensed Tank Tester <br /> License Type: License Number: �� <br /> Manufacturer Training <br /> Manufacturer Component(s) Date TrainingEx ires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> rf /! O ❑ ❑ ❑ ❑ 0 0 <br /> 0 0 'Q 0 0 0 ❑ <br /> F'11 jy� 0 0 0 0 ❑ 0 0 <br /> ❑ ❑ 0 ❑ ❑ ❑ 0 ❑ <br /> 0 ❑ ❑ ❑ 0 ❑ 0 ❑ <br /> 0 0 0 0 ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ 0 0 0 0 ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ 0 ❑ <br /> ❑ o ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ 0 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> Date: io <br /> Technician's Signature: 1 %llt1� <br />