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REC�L ��✓�[�L=! <br /> SIVR.;B,January 2002 Page of <br /> Secondary Containment Testing Report ForinE MAY 2 0 2004 <br /> NVIRONN <br /> This•form is intended for use by contractors performing periodic testing of UST secondan-containment=rocl <br /> i QHEALTH <br /> appropriate pages of thisform to report results for all components tested The completed form, written <br /> printouts from tests(if applicable), should be provided to the facilizv owner.•'operator for submittal to the locai regulatory agency. <br /> 1. FACILITY LNFORMATION <br /> Facility Name: d t G72 p j Date of Testing: <br /> Facility Address: >Zr <br /> in <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testin - <br /> 2. TESTING CONTRACTOR WFORMATION <br /> Company Name: C <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Conft=or ❑SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> M9nafactnrer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass FaR TN�otd I�� Component Compomt PaFail Not Repairs <br /> Tested Made <br /> I <br /> ❑ ❑ ❑ ❑ ❑ ❑ n <br /> Li <br /> a ��,, ❑ — ❑ I ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> s ❑ ❑ r❑ ❑ ❑ <br /> ❑ � ❑ J ❑ ❑ ( L.r � LI <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> F i4�., d v <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: '��' ��' <br /> c- <br />