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SWRCB,January 2002 Page I 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: o -e Vb Date of Testing: -27 _ Q <br /> Facility Address: 12-10 ! _ o Ln . eeK e . "'2 a <br /> Facility Contact: Phone: -2-0 -K2-3-/3'f <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> -CompanyName: 2 6 45"'_ <br /> Technician Conducting Test: _ i <br /> Credentials: j?.CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> License Type: / i°Z ,, r LLicense Number: G'3 '. <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Traininp,Expires <br /> 3. <br /> SUNPVLARY OF TEST RESULTS <br /> II Not j Repairs Not 'Repairs <br /> Component Pass I Fail Tested I Made Component I Pass Fail l Tested 1 MadeMW I <br /> %c - � D � 0 0 I ❑ ❑ D ❑ <br /> l� t / - ,� ❑ I 0 ❑ ❑ ❑ ❑ D <br /> ❑ O D 0 D D � 0 ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> D D ❑ D ❑ ❑ D I ❑ <br /> O D 0 D ❑ D ❑ ❑ <br /> ( D 0 D ❑ D ❑ ❑ ❑ <br /> ❑ D D ❑ ❑ 0 1 ❑ 1 ❑ <br /> ( ❑ ❑ ❑ D D O 0 ( D <br /> 0 0 ❑ ❑ ] D Lo 1 ❑ 1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Aj& TRK. �z b,-- ►re g.tz CA e� <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING Ti IS'TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> !7 <br /> -2? - <br /> `Signature:— 1 �'7� 1'�°'�- Date: 2 <br />