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AUG 2 2803 <br /> SWRCB,Ianuary 2002 3 ��CE ' `aWrRGEiVW. or-11 IO Page of 3 <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: A Date of Testing: � Q <br /> Facility Address: v- L <br /> Facility Contact: L Phone: 2 6 9 - <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ,� <br /> Technician Conducting Test: QP1J07— <br /> Credentials: 4-CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: )4, c License Number: (p 3 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Ex ires <br /> S -7e-6T Pen e7' l <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fait Not Repairs <br /> Tested Made Tested Made <br /> o Fs� I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> < ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> g-I ❑Or ❑ ❑ ❑ ❑ ❑ ❑ <br /> x 18'1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> m ou 22 1 .0-1 ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> box g �- ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> ❑ ❑ ❑ 1 E) ❑ ❑ ❑ ❑ <br /> ❑ 1 13 1 ❑ ❑ ❑ ❑ I ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> rem l,e4 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my Icnowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />