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Secondary Contaimmopent Testing Report Form Am <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: � , - -7� Date of Testing: f <br /> Facility Address: f QQ R <br /> Facility Contact: , (o Phone: <br /> Date Local Agency Was Notified of Testing: 4. <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION: <br /> Com an Name: <br /> Technician Conducting Test: P, JU II i,- <br /> Credentials: ❑CSLB Licensed Contractor RCB Licensed Tank Tester <br /> License Type:. License:Number: 114' <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUNEVLARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ ❑ ❑ <br /> _, ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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: j <br /> Technician's Signature: �` Y r <br />