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I A�13 E C:�q E�V E 0 <br /> Secondary Containment Testing Report Form - DRAIN 3 1 2003 <br /> This form is intended for use by contractors performing periodic testing of UST secondary conhainmeWA ENT HEALTH <br /> systems. Use the appropriate pages of this form to report results for all components tested. The'F Wvi1T/SERVICES <br /> completed form,written test procedures, and printouts from tests(if applicable), should be provided to <br /> the facility owner/operator for submittal to the local regulatory agency. <br /> _ 1. FACILITY INFORMATION <br /> Faci ' Name: S ry le-t Date of T o? <br /> Facility Address: 3 <br /> FaciliContact: X04.N R c = Phone: <br /> Date Local Agency Was Notified of Testing: - J <br /> Name of Local Agency Inspector Present: <br /> __ 2. TESTING CONTRACTOR INFORMATION <br /> CNam�o-- e: I C-QST LTi <br /> Technician Conductin Test- <br /> � 00+' <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> Licensepe — <br /> Trainine by Manufacturer --- —_ <br /> Manufacturer �Component(s) Date <br /> Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: I Number of Piping Runs Tested: <br /> Number of Submersible Pum Sumps Tested: Q Number of UDC Boxes Tested: <br /> N� umber of Fill Sumps Tested: Number of Overfill Boxes Tested: — <br /> Com —HentPas Fad Comments <br /> .moo c, �vhl�1.(1 ®- ❑ --- --- <br /> ❑ <br /> e4 Uln <br /> ❑ -- <br /> ❑ ❑ <br /> ❑ ❑ _ <br /> ❑ ❑ _El 11 <br /> ❑ <br /> ❑ ❑ -- <br /> ❑ ❑ <br /> ❑ ❑ — <br /> ❑ ❑ ---F1 F1❑ <br />