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06/03/2004 07:58 2094683433 FIFTH FLOOR PAGE 03 <br />SWRCB, MUM 2002 <br />of J <br />Secondary Containment Testing Repo Form <br />This form Is intended for use by contractors performing periodic testing of UST second4ry1AWWa <br />l <br />'toWrOP7210pags of thisform to reporf results for all COMPOWMs tested, r1itconp1cradform,written test <br />-Mff <br />irkL <br />printouts from tests (Yapplicable), should be provided to thgfacility owner/operator for submittal jo the local <br />regulasoly agency. <br />1. FACILITY IN'FnR1,AAnnfv <br />facility Address: <br />Facility Contact: <br />Date Local Agency Was Notified <br />Nam of Local A 2encv Inenectnr <br />2. TESTING <br />cojnp�m Name: <br />Technician Conducting Test <br />Credentials: J(CSLB Licensed Contr <br />License Type: A - + e - i o <br />Date Of Te., <br />'TRACTOR INFORMATION <br />D SWRCB Licensed Tank Tester <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests; <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIUS TESTING <br />7*0 the bat of my knowledge, thefmrs stated in this document are accurate and in fall conrliance with legal requirements <br />Technician's Signature: <br />—.4 — Q4-- Date;. <br />S114411111V OF TEST <br />RESULTS <br />!1A 114,1 <br />■ <br />Meow it'. <br />owns <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests; <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIUS TESTING <br />7*0 the bat of my knowledge, thefmrs stated in this document are accurate and in fall conrliance with legal requirements <br />Technician's Signature: <br />—.4 — Q4-- Date;. <br />