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SWR(!'M, January 2002 Page' EA of <br />• I , 1 1. 1 ji <br />Secondary Containment Testing Report For <br />I, <br />This form is intended for use by contractors performing periodic testing of UST secondary conk' e st U, the <br />appropriate pages of this farm to report results for all components tested The completed fonn t U o 49 <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />1. FAC TUrY INFORMATION <br />Facility Name: 5 -,4p -AQ Date te of Testing: <br />�f &�vzp, d- . , '71216 <br />Facility Address:1110 /1/10r�zl) C4, <br />Facility Contact: _P'4C;&C Phone: L <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (1fpresent during WM99): <br />r entia1s: CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />Man1facturer Zraining. <br />-Manufacturer Component(s) Date Training Expires <br />KIELI <br />111i111. ; s 114 Vi 0 N K <br />Component <br />Pass Fad <br />Not Repairs I <br />Tested Made Component <br />Pass <br />Fai <br />Not <br />Tested <br />Repairs <br />Made <br />El <br />01 <br />❑ <br />El C1 <br />11 11 <br />El 1 <br />I'D <br />FF -1 <br />0 <br />0 0 <br />0 n <br />ol <br />:I <br />E, <br />1i <br />0 11 <br />Cl El <br />El <br />11 <br />11 <br />11 <br />n o <br />o r -i <br />r-1 <br />1 11 <br />E -i <br />El <br />El 0 <br />El 0 <br />0 <br />11 <br />0 <br />11 <br />11 11 <br />0 0 <br />0-1 <br />0 <br />El <br />11 <br />13 0 <br />11 13 <br />10 <br />❑ <br />0 <br />11 <br />❑ 0 <br />❑ <br />L7 <br />El <br />El 0 <br />C1 11D <br />11 <br />M <br />D, <br />El <br />r <br />t L <br />If hydrostatic U--Mng was performed, describe what was done with the water after completion of tests: <br />CERTMCATION OF TECHNIC IAN 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 />