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Secondary Contair—ent 'Testing Depart Form <br />This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appr•opr•iate pages of this form to report results for all components tested. The completed form, written festprocedures, and <br />printouts from 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: Q &?-'Date of Testing: 3116 G <br />Facility Address: D( ,E. </X,QT,e t✓_ A 'SToc_(e_-re, tJ cA 5aD6 <br />Facility Contact: I Phone• ;2,n)y 67- 63505 - <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING'CONTRACTOR INFORMATION <br />Company Name: 7� S 7 <br />Technician Conducting Test: I114mo <br />Credentials: ❑ CSLB Licensed Contractor OK SW.RCB Licensed Tank Tester <br />License Type:. License.Number: pd <br />Manufacturer Training <br />Manufacturer Component(s)) Date Training Expires . <br />3. SLTTvUvL4,RY OF TEST RESULTS <br />Component <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />V_ie� <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of nzy knowledge, tine facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature. '" ' bate: - 5 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />V_ie� <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of nzy knowledge, tine facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature. '" ' bate: - 5 <br />