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*RECE <br /> IV <br /> SWRCB,Jan 2002 pa e �® <br /> Secondary Containment Testing Report FormMAY 2 3 2013 <br /> This form is intended for use by contractors performing periodic testing of UST secondary �c t Inis. Ll'SLI the <br /> appropriate pages of this form to report results for all components tested. The completed form 't . c .tLTH <br /> printoutsfromtests(ifapplicable),should beprovidedtothefacilityowner/operatorforsubmittal tODE ; 8N:ugcncy. <br /> I. FACILITY INFORMATION <br /> Facility Name: ---,e> I Date of Testing: <br /> Facility Address: IZ11 jf 409 , rAlleGrpOP0 C'$3- <br /> Facility Contact: ga Phone: �j"---,2-70 �1 <br /> Date Local Agency Was Notified o9testing: <br /> Name of Local Agency Inspector(f present during testing): yl <br /> 2. TESTING CONTRACTOR INFORMATION <br /> .......... ... <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials: 7 CSLB Licensed Contractor f a SV4'RCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fait Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> .111 56f4.fiawr ❑ D D ❑ n c f-1 <br /> 9-7 it �i 0 El D ❑ LJ L <br /> t ❑ ❑ D ❑ ❑ ❑ <br /> + Z 000 ❑ ❑ ❑ ❑ ❑ ❑ <br /> 314 V - D ❑ ❑ ❑ ❑ ❑ _J <br /> itiNt. 0 fie ❑ ❑ ❑ --- ❑ L ❑ D <br /> #fir 00 C- ; ❑ i❑ D 1 ❑ D ❑ ❑ <br /> 2r 7 IV 2- 4, •^ ❑ El ❑ ❑ ❑ t ❑ <br /> r.j L7 ii <br /> Ci I 01 ❑ 1 ❑ ❑ ❑ ❑ ❑ <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 document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />