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Lq <br /> Ec wa <br /> SWRCB,January 2002 M I G 1 5 7005 Page 1--of <br /> Secondary Containment Testi mr ," <br /> This form is intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested. The completed form,written test procedu es,and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Q.7 ` ir 1).1 Ct8 pate of Testing: Q 05 <br /> Facility Address: (023 U ccc 4 't S�u s-20 <br /> Facility Contact: P one:610 1) $'? —fj 515 <br /> Date Local Agency Was Notified of Testing: -M-5 <br /> Name of Local Agency Inspector Cif present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: i a-- Ge- GS ✓s <br /> Technician Conducting Test: ,,; ,,, ,^. , <br /> Credentials: U CSLB License Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number. 170-111 2-0 <br /> Manufacturer Training <br /> Manufacturer Com nen s Date Training Expires <br /> 3. SUN04ARY OF TEST RESULTS <br /> Component Paas Fail Not Tested. Made Component Pass FailNot airs <br /> Tested p <br /> _64AIlitWC+Z <br /> ta✓ Gce� Z U.0C.# 3 4- <br /> 5C C61 JOV <br /> 5eC61JOV t? > > > uv)(-A0 zu) <br /> Cara c,*12.. <br /> 9. 4ubLf1S£r,/6 <br /> r, S 3 > > > (AW - 1'7 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> r Gt oj,� � V ,r'O 6w IPt <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in document are accurate and in full compliance with legal requirements <br /> Technician's Signature:' Date: <br />