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SWRCB, January 2002 RECEIVDPa <br /> ge Secondary Containment Testing Report Form JAN <br /> 1 S 2011 of <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmft ,I EALTH <br /> appropriate pages of this form to report results for all components tested The completed form, wriA C <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to th�ocal regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: S te-42Ltt / d e.r O Date of Testing: .,. .. 1 0 <br /> Facility Address: Vav•I-in ELL- D ej <br /> Facility Contact: /'�( O e e� �ti. ` [ Phone: L-2-c <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: P— t I 1.l a.��. 2 1 s m <br /> Technician Conducting Test: 7_:--, e„`1 a LavV <br /> Credentials; 0 CSLB Licensed&o-tractor SWRCB Licensed Tank Teste <br /> License Type; r t,A Ic -e,✓ License Number: _c <br /> Manpfacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fifil Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> `i eelK Ja k4 Pi t.R, ❑ ❑ 0 (t( �. L ❑ 0 ❑ <br /> c env rt�� r ..��`� ❑ ❑ ❑ �� I 1 � s � ❑ ❑ ❑ <br /> eeWjci ► j< ❑ ❑ ❑ ❑ ❑ ❑ <br /> ,�e. ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �? JI ❑ ❑ ❑ ❑ ❑ 0 0 <br /> if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated In this do ent are accurate and in full compliance with legal requirements <br /> Technician's Signatu : ,.� l -�- Date: V _ <br />