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I <br /> U SS <br /> SWRCB,January 2002 �"7of _ <br /> k�z: <br /> SecondaryContainment esti Report or �D <br /> , P #, � <br /> This form is intended for use by contractors performing periodic testing of U.ST secondary contain-Aithe' <br /> '/�,( ms. 7.V41 ' <br /> appropriate pages of this form to report results for all domponents tested. The completed form, writ Y� es, and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to , '/Wency. <br /> 1. ACILITY INFORMATION <br /> Cis 'j7 _ <br /> Facility Name: Date of Testing: - 6 <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local AgencyCWas Notified of Testing: <br /> Name of Local Agency Inspector(rf present dur g testing): <br /> TESTING CQNTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conductin est: `j ..u,7– <br /> Credentials: CSLB Licensed Wntraclur ❑ SWRCB Licensed Tank Tester <br /> License Type: ACQ License Number: ' <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> u 9, ❑ ❑ ❑ �` <br /> ❑ ❑ ❑ G fid' ❑ <br /> X ❑ ❑ ❑ p� C ,� ❑ C - <br /> u- ,� ❑ ❑ ❑ x ❑ <br /> ,�' ❑ ❑ ❑ 44P e ,� ❑ n <br /> ❑ ❑ ❑ L_j D <br /> ❑ ❑ ❑ ❑ ❑ <br /> , C ❑ ❑ ❑ ❑ ❑ <br /> El <br /> ❑ 1 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after compl tion 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 /> Technician's Signature: Date:— �� __ <br />