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Secondary Containment 'Testing Report Form <br /> tn <br /> This form is Intendedfor use by contracto,-„erforming periodic testing of UST secondary _-)ntainment 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: �e� U /�/r Date of Testing: �S ( o !o <br /> Facility Address: "3 p(�/V 1100 At ol Cd 96-36 <br /> Facility Contact: E,�Jf� Phone: 5 -- G 6 <br /> Date Local Agency Was Notified of Testing : '7 /L/ D�O <br /> Name of Local Agency Inspector (fpresent during testing): <br /> 2. TESTING''CONTRACTOR INFORMATION <br /> Company Name: r-o9 A- <br /> Technician Conducting Test: NE (MhiO <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: . I License.Number: 0 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires . <br /> 3. SUryMURY OF TEST -EVSULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> P�SEL - ( El El El El <br /> ❑ ❑ ❑ ❑ <br /> Z X ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Mat IJ X ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ <br /> e�®r ❑ ❑ ❑ ❑ <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 fall compliance with legal requirements <br /> ;( <br /> Technician's Signatur Date: 8/1 04” <br /> i <br />