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SWRCB, January 2002 Page 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 rhe <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: 3 <br />Facility Contact:Pho e: CJ _ :2_1�-® <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING C'ONT14 ACTOR PVW0RMATTnN <br />Company Name: 4— <br />Pass <br />Technician Conducting Test: <br />Not <br />Tested <br />Credentials: CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: <br />ufacturer <br />License Number: <br />IVlanufacturer Training <br />Component(s) Date Training Expires <br />3 . SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />Fail <br />Not Repairs <br />Tested Made <br />I <br />I <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 bestof my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signa e: Date: !fir v l �� <br />