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SWRCB, January 2002 <br />Page -- of 7 WW <br />Secondary Containment Testing ReportF*,LL_[VW <br />._��_. [D) <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completedform, writt t.Vr6ce 4s, and <br />-- printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the loe--r-regulatory agency. <br />ENViRONP0ENT' HEALTH <br />IL <br />1. FACITY INFORMATION <br />Facility Name: q ; rye, z( 47,s 7 47, , i T-) <br />I Date of Testing: / <br />Facility Address: ea, S J' �, ao, ,, je <br />jk, <br />Facility Contact: rl bt e�NGi jn r'J r �e :its <br />Phone: (� ,n _ i'I <br />iN <br />Repairs <br />Made <br />Date Local Agency Was Notified of T sting: 12-13VOo <br />Manufacturer <br />Name of Local Agency Inspector (fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION E^1V RONi'�1ENT -HFAO. H. <br />CompanyName: d,, i au�e <br />� <br />Technician Conducting Test: H 'tet" wtza�'� <br />jk, <br />Credentials: ❑ CSLB License Contractor <br />WRCB Licensed Tank Tester <br />License Type:: le- Ts ey <br />Repairs <br />Made <br />License Number: –1/ZQ <br />Manufacturer <br />Manufacturer TralnlnE <br />Component(s) Date Training Expires <br />lil.l.cl illy al e– <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component Pass <br />Made <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />lil.l.cl illy al e– <br />❑ <br />❑ <br />❑ f 1 :l:t 7 t fl <br />❑ <br />❑ <br />❑ <br />l/ttc ;I � , o 3 <br />❑ <br />❑ <br />X- <br />❑ ❑ <br />❑ <br />o <br />❑ <br />eco dui o d <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />> e celI J 0 14 AWP ptZ. <br />V❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />�,t,�t :;1 <br />❑ <br />❑ <br />❑ ❑ <br />0 <br />❑ <br />❑ <br />❑ <br />11 <br />El El <br />0 <br />❑ <br />/� <br />flA.0 f. / 7� <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />j{l1 f <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />�! f <br />0 <br />❑ <br />0 ❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with t water after completion of tests: <br />{ 1 s 1111 / A s U n 11,P�� co .:.! �� t/.0L•r rc b V A s� <br />CERTIFICATION OF TECHNIC SPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated InV*docment are accurate and infull compliance with legal requirements <br />Technician's Signator : �—' I Date: l 3 U <br />