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r SWRCB,January 2002AUG200Page of 1 <br /> Secondary CkwitMuffiftfUtting Report For <br /> t This form Is intended for use by contractors perf c(2E&g of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results.for all components tested. The completed form, written test procedures, and <br /> printouts from tests (if applir 51e), should be provided to the,facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: �' -�d.� t'/)'f ( 0 r t,) Date of Testing: <br /> Facility Address: _ ✓/a " t-E r 7,a r - . r ; "r, 3. f <br /> Facility Contact: 54--e,j o �_ �� 4'�),' Phone: ('�>�� <br /> 3 5 <br /> Date Local Agency Was Notified of Testing: ,9( r•) <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:71 -777-77, {, fi <br /> Technician Conducting Test:?. ,� t E , r j 0 <br /> Credentials: ❑CSLB Licensed tontractor WRCB Licensed Tank Tester <br /> License Type Y s,�Q <- *a, License Number: ' () O <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin Ex ires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> El El El t, (` 2 El El 11 <br /> Ag"I t � �° .. ❑ ❑ ❑ 1..) 1 f ❑ ❑ ❑ <br /> ®® ❑ ❑ ❑ <br /> ❑ <br /> . f x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> p ) <br /> { Ld E: '$ '16 " �r :`''�*� �°�/4` ��e- fat � ��� �YL r"� <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,,diefacts stated in tlrlsocmment are accurate and in full compliance with legal requirements <br /> 11 0 <br /> O. <br /> Technician's Signature /�. 1 ., , - - Date: y / C <br />