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Secondary Containment 'Testing'Report Form <br />This form is intended for use by contra s performing periodic testing of UST secon containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, <br />I. FACILITY INFORMATION <br />Facility Name: 1 (c C("� C,if F'e'z , & Date of Testing: 1-7 � N G (, <br />Facility Address: -� [ l�f C �l <br />ri �ZI C ri�o� �2 <br />Facility Contact: t2 v iv Phone: '-�3;3;i—Cfd 7`) <br />Date Local Agency Was Notified of Testing : rf 5 U Lp <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTINGCONTRACTOTI TWOMMATTnN: <br />3. u V lU Y OF TEST EV cUL 3 O <br />Com onent Pass Fail Not Repairs <br />p Tested Made Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />• 67-( ( r <br />❑ . <br />❑ 1 <br />❑ <br />0 <br />❑ 10 <br />1 <br />❑ 1 <br />❑ <br />--Z,� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ 101 <br />0 <br />0 <br />❑ 101 <br />❑ <br />❑ <br />0 <br />❑ 1 <br />❑ <br />❑ <br />❑❑ <br />❑ <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />/,,'74 7C-1411,/l6A'7� <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />'b the best of my knowledb e, tine facts st ted in this document are accurate and in full compliance with legal requiren uts <br />echnician's Signature: Date: <br />