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U rr i.�..i-,, .,uilua,y LIJ,.L <br /> Secondary Contair-7ent Testing Report Form <br /> T17 isform is intended for use by contracta-s performing periodic testing of UST secondary 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: / /,-10 Al 7- L OJ Date of Testing: -,s-// <br /> O 6 <br /> Facility Address: -2-to,5 r/2,6/t,10nf`' :5-r C-& 5 <br /> Facility Contact: A- I I Phone: <br /> Date Local Agency Was Notified of Testing: U z /0(,o <br /> Name of Local Agency Inspector(fpresent during testink): <br /> 2. TESTING CONTRACTOR INFORMATION: <br /> Company Name: <br /> Technician Conducting Test: -4NO /V mm 0 <br /> Credentials: ❑ CSLB Licensed Contractor XSWRCB Licensed Tank Tester <br /> License Type: I License.Number: p <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires . <br /> 3. SUWAARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested RepaiMada Component Pass Fail Tested Made <br /> 07 0-_[ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> I 0 C--r ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> �iEs�L ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> V-e Vj <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my kno►vledb e,tl act sta rr-th•s document are accurate and in full compliance►pith legal re44 quirements <br /> Technician's Signature-. _ Date: <br />