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z SWRCB,January 2002 Page -L 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(rf applicable), should be provided to the facility owner/off ator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: t.?eh-,j tAlt r�D Date of Testing: <br /> Facility Address: (r,L43'] - <br /> Facility Contact: t.._; �,Ap hone: (Zo _ <br /> Date Local Agency Was Notified of Testing: - <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION ENVIRONMENT HEALTH <br /> Company Name:-F- <br /> Technician Conducting Test-:—U2 `, r et v,- <br /> Credentials: ❑CSLB Licensed Itontractor CB Licensed Tank Tester <br /> License Type: &�. �� <br /> �r� �- .y License Number: 0 -1111-0 SCC'' P �`� <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires ' <br /> 3. SUIWAIARY OF TEST RESULTS <br /> rs ai <br /> . .Component Pass Fail Not Repairs ' Component Pass •Fal{ Not...: Repairs <br /> Tested Made Tested Made <br /> tttd cc.d ❑ ❑ <br /> 11 El <br /> e , � ex 3 ❑ ❑ I'D 1 ❑ 0 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> k " L ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> a ' 3 ❑ 0 ❑ 0 ❑ 0 0 <br /> 7 0 ❑ ❑ ❑ ❑ ❑ 0 <br /> If hydrostatic testing was performed,describe whats done with the water after completion of tests: <br /> rA [c <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In this 4oquinent are accurate and In full compliance with legal requirements <br /> Technician's Signaturei Date: <br /> AJC <br />