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SWRCB,January 2002 <br /> Seconclary C®ntai ent Testincr 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: rI Date of Testing: ®— <br /> Facility Address: <br /> afv <br /> Facility Contact: n � � Phone: -AO <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTINO'CONTRACTOR INFORMATION: <br /> Com an Name: <br /> Technician Conducting Test: , LY14pz- v ' <br /> Credentials: ❑CSLB Licensed contractor 819VRCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> P 'Tested Made <br /> n ❑ ❑ ❑ ❑ <br /> 0 11 0 El <br /> Ile <br /> �� ❑ ❑ ❑ 0 <br /> ❑ ❑ 0 0 <br /> ❑ ❑ ❑ 0 <br /> ❑ ❑ 0 0 <br /> ❑ ❑ 0 0 <br /> ❑ ❑ ❑ ❑ <br /> ❑ 110 ❑ <br /> EH ❑ 0 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> yl <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 /> 'f ' az Date: (� .. <br /> Technicians Signature,_ . P' <br /> j,: <br />