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Secondary Contaient TeStin; Report Form <br /> .This form is intended for use by contract pl el forming eriodlc testing g o j UST secovrdaco1ztailrment 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 frons tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Facility Name: A jf,1a p4 I Date of Testis <br /> Facility Address: I D S , g © �' <br /> -A i 12J�12-T A 7STpc-I/-�aN <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: Q <br /> Name of Local Agency Inspector Wpresent during testing): <br /> 2. TESTING'CONTRACTOR EVFORMATION� <br /> Company Name: FFo�D� — 'T��-� . <br /> Technician Conducting Test: lMl�b <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer Corn onent s <br /> Date Training;Expires . <br /> 3, SLWVIAR Y'OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not ]Repairs <br /> Tested 87 Made Component Pass Fail Tested Made <br /> El El <br /> II OC ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Li <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> El D ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> r �T~{ <br /> CERTIFICATION OF TECHNICIAN RE'SPONSIBLE FOR CONDUCTING THIS TESTING <br /> To ilia best of my knoWedg e, the facts staied in this document are accurate and in full compliance Ivitl3 legal requiremenis <br /> Technician's Signatur <br /> Date: 1616 � <br />