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SWRCB, January 2002 <br /> Page Secondary'Containment Testing Report Form 0 - 2003��f— <br /> Mis orm is intended-for use cdmractors ENVIRD + <br /> fby performing periodic testing of UST secondary coy T <br /> appropriate pages.of this form to report results for aU components tested The completed form, ' <br /> Priraouts from tem(fappUc+bb:),Amid be provided io the facility ownerloperator for submatai to the local regulatary agency. <br /> 1. FACEUTY INFORMATION <br /> l7acility Name: d - A di A�Q7` Date of T O .. <br /> Facility Address: fpr ;t/ S oto <br /> Faclity Contact: G i P O 2 1 <br /> Date Local Agency Was Notified of Testing: 1 a ,j <br /> Name OfLocal Agency Inspector(if present awing iestmo: <br /> Z TESTING CONTRACTOR INFORMATION <br /> Co Name: _' t v c�, �2y ___ <br /> Technician Conducting Test a 9 J — <br /> Credenuals: CSLB Licensed Contractor ❑SWRj2t Licensed Tank Tester <br /> License Type: L �r Cq) License Number: <br /> Manufacturer Training <br /> Manufi ti ter COmDO sl Date T Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Ful Tested Made Component Pts TNested Made <br /> e ❑ 0 ❑ ;' <f 7 ¢ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> ' 6 S ❑ ❑ ❑ Pis' a ;., , ❑ ❑ ❑ <br /> "t " an/ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> to �' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> � > i✓ " u� ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> .sal ✓ rti a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> G ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> frf� SLOG I v1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> uy G f � ❑ ❑ Cl In <br /> ❑ ❑ ❑ <br /> J . G 5 6 ❑ 11 Cl ❑ ❑ ❑ ❑ <br /> Ifhydrostatic testing was performed, describe what was dote withthe water after completion of tests: <br /> r <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts/stared in this document are accurate and inU fueanT iance wij*Iegal nquire n is <br /> 41 <br /> Technician's Sigorture: .�X',, zz& Dare: /� �� <br />