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S WRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> 77ris orm is intended or use b contractors MAR 1 2 2003 <br /> f f Y performing periodic testing of UST secondary conuumnew systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form, wriuengWpq*tMMT WdALTH <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the IpM p cy, <br /> 1. FACILITY INFORMATION <br /> Facility Name: — IG Date of Testing: /KIItiZC►} Xj O <br /> Facility Address: <br /> Facility Contact: ,148go Phone Qo 83 <br /> Date Local Agency Was Notified of Testing: _ p <br /> Name of Local Agency Inspector(rf present during testino: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: --jp� t <br /> Technician Conducting Test: YkaTyyZ o� <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: L i License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass I Fail Not Repairs T a Component Pass Fail Testmed Made <br /> l P 0 ❑ ❑ 0 ❑ 1 ❑ <br /> vmP ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 0,3 Some ❑ ❑ ❑ ❑ 0 0 ❑ <br /> . ( PaW, ❑ ❑ ❑ ❑ 0 0 ❑ <br /> Z apl>4 ElC1 ❑ 1 11El 0 ElJ�-? a°IPrJ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> 4/ u ❑ ❑ 0 ❑ ❑ 0 ❑ <br /> -g11/ ey, ❑ ❑ ❑ ❑ ❑ 0 0 <br /> -4(2 D IS P2,05�2 ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LIU/Uo Fr 14e�oc{ n,1A t r--� t .rA Ie C Cb.cl�l i�� �ml <br /> oocleJ�o hFl\r�. e .�\L <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:1^7AQCff- _3 03 <br />