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OCT 1 0 2003 <br /> SWRCB, January 2002 Page Of <br /> HEA LTI� I <br /> $ 111 A HEALITF <br /> Secondary Containment'Ttst vRport Form " ,',% F <br /> This form LY intended-for use by cong-acrors performing periodic testing of USTsecandary c"TTnj j,, e <br /> appropr iale pages T�this form to report r e.�u Its for all components tested The completed fbFni, wrr tien te.s=proct-0S, and <br /> pri.ntnuisftom te3is(if applicabie), should he provided to dzejacility ownerlbperatorfor submirrai to the Local regulatory agency. <br /> 1. FACH-M INFOILMATION <br /> FaeflityName: I Date of Testing. <br /> Z Y, <br /> Facffity Address: <br /> Facility Contact: 'C).p C,�- <br /> (I C-A Phone: <br /> Date Locai Agency Was Notified-o-i'Testing: <br /> Name ofLocai Agency lWector(ffprasent during tom: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> comparry <br /> Tecbrdcian Condacting Test: <br /> Credentials- CS1B Licensed Coutracxor El, Licensed Tank Tester <br /> License Type: License Number: <br /> Mlnu&qwrer Dmkjig <br /> compone*s) Date Train�Expires <br /> 3. su3cMARY OF TEST RESULTS <br /> Fail Not Rqiaim component Pan Fafl Not Repairs <br /> V Pin Tested Made Tested i Made <br /> 11 0 <br /> 11 E, <br /> 3 .7 E 11 <br /> f-1 11 <br /> S <br /> 0, El 11 0 0 W�WA ❑ �- [I C1 <br /> [I El <br /> C1 L-1 11 11 L-11 0 ci 11 <br /> El 11 El 11 <br /> E <br /> 0 - C1 , Ej EI <br /> If hydrostatic testing was performed, describe what was done with the water ager con*etion of tcam <br /> C <br /> j- <br /> CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this dw-umeware accurate and in full eomTfiance widt legal requirme�"� <br /> Technic--an'3 Siziirure: Date: <br />