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♦ 4 <br /> SWACB,January 2002 �, i��4.NIAItHEAl-Iii p <br /> �J:viCF I of L <br /> Secondary:Cuntainment Tesp arm <br /> �qq <br /> This farm is intended for use by ed>iM=rs perfarmotg perlo&, g S recondory cnntarmnem tysiems LGe <br /> appropriate pages ajthis farm to reprnt ressdts for all components tested The completed form, written test prccedares, mi <br /> printouts from tests f applicohle),should he provided to the facility owner/operator for submittal to die laral regulatory agw= <br /> 1. FACILITY INFORMATION <br /> Fac*yName: EM1k,j L, v 27 S Date of Testing: P2/ i <br /> c'a' <br /> Facility Address: i ya S, � C i Fdll o E SCA t c N C A , <br /> Facility Contact: C14AC140 ±hAAY Phoma: "01-93'k- 761 <br /> Date Locai Ageacy Was Notified afTesting: t r /7 Y/o.3 <br /> Name or Local Agency Inspector#presetd&wmg moo g): <br /> 2. TrsnNG CONTRACTOR RWORMATION <br /> Company Name: t ^T2 <br /> Techme a Conducting Test: A L✓; ta t[ AA; J <br /> Credentials: A CSLB Licensed Conaactor ❑SWRCB Licensed Tank Tester <br /> LicenseType: rL11 <br /> > �� License Number: <br /> M=1miac t urer Tramin¢ <br /> Maturer C4xws9 Date T Finites <br /> 3. SUMMARY OF TEST RESULTS <br /> Com Paul Facdrim Diepoirs Cwopmaeot Pau Fab Not Rgwn <br /> Tesadt Made Tested Made <br /> ❑ ❑ ❑ ❑ ❑ ❑ I ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 01 ❑ I ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ifhydrosta=testmg was performed,desrnbe who was done with the water after comptem m of ie sm <br /> T <br /> CERTIFICATION OF TECHNICIAcN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts wed in t"darwnent are acomde and its full cunmliamca with legai requirements <br /> T cihaiciau'a Simmure: i.. ''� �e"` a -r.� Date: !Z/ t/a`3 <br />