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" . -1 , 0 HECI,- WEDD MAI <br /> swRCB, January 2002 K�ffngPage IofSecondary Containment Testln 'ieporm. <br /> d ! i H <br /> This form is intended for use by contractors performing periodic lesti �� ' K � <br /> E�l^�`�, tnment systems. Use the <br /> appropriate pages of this form to report results far all components tested. � �4Jt� ' written test procedures, and <br /> printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Le lhy-uo 6efsd j'rf u I Date of Testin <br /> Facility Address: I + e) r tea, ` rlWt r' t f <br /> Facility Contact: ; ,p 1- t,, 2--r l <br /> Date Local Agency Was Notified of Testin : <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name; L\0.-, etAAX e--' v� <br /> Technician Conducting Test: lei,,;.fL. t.i ttdt. ft , <br /> Credentials; ❑CSLB Licensed tontractor AWRCB Licensed Tank Tester <br /> License Type:' \e–. �' �. License Number: '7 t " <br /> Manufacturer Train' <br /> Manufacturer Component(s) Date Training Expires <br /> I SUMMARY OF TEST RESULTS <br /> Component Pass Fall Not Repairs Not Ftepairo <br /> p Tested Made Component Pass Fail Tested Made <br /> f t!l I Y CG6 ;$Gee ❑ ❑ ❑ ❑ 11 F1 ❑ <br /> J b f ��C . ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Se-C&A.AA J p z- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �ec�vtda� ❑ ❑ n ❑ ❑ ❑ ❑ <br /> I �.,,, �K - .y ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ' t �W� ►,tc• 3 ❑ 7 ❑ ❑ ❑ ❑ rJ <br /> Li <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING TNIS TESTING <br /> To the hest of my knowledge, the facts stated It t d!t cument erre accurate and in All compliance with legal requirements <br /> Technician's Signature; __-�-- <br /> �. ,l --—..-- Date: <br />