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S WRCB,January 2002 • <br /> Secondary Page ( of (o <br /> This form is intended for use by nda ry CORttainment Testing Report Form <br /> appropriate pages ojthis form to report results for all ampanents�pstegdof UST seconds <br /> Printouts from tested <br /> s i a licableJ, should be ry condf <br /> arm,tainment syslesttem Use the <br /> (f PP f i y owner/opera or for submittal tot the local I Ures, and <br /> Provided to N+e act/' <br /> I. FACn,TTY INFORMATION r 'lQ1Oiy agency. <br /> Facility Name: <br /> Facility Address: D y O Date of Testing; <br /> Facility Contact: Y1S C K L L <br /> Date Local Agency Was Notified of Testing: F Phone; _ O _ <br /> Name of Local Agency Inspector rYpresent during lest, g/ <br /> �/anlE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com Name: R <br /> Technician Conducting Test; 4 un° Cl��c <br /> Cmdentiais: L CSLB Licensed Contractor <br /> License Type; ['I SWRCB Licensed Tank Tester <br /> A2-Yhli r -/O License Number t/872-1 Sys <br /> Manufacturer ManutacR r : <br /> ¢� Com onent s <br /> - t�D Date Tra' ' Ez LreS <br /> 3. SUMMARY OF TEST RESULTS <br /> Compooeat Pass Fail Not Repairs <br /> N Tested Made Component Past Fall Not Repairs <br /> V' I J _ <br /> Tested Made <br /> rl J Ci <br /> W. 1X Ll ❑ I j ( ' r1 <br /> IF Ll <br /> Li <br /> „ L, <br /> w Sone r° l u u <br /> L <br /> A) JAbC=— Ivy' Ll ' L, J <br /> if hydrostatipc testing was Performed,describe what was dose with the water after completion of tests: C LI <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING ' <br /> Tr the best ojmy knowledge,rhe — <br /> jaca swied in this document are accurate and in jall compUmce with legal requirements <br /> Technician's Signature: <br /> — — — -- Date:_/ 2 —//-0L— <br />