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SWR?-'13,January 2002 NOV 1 2 2002 Page of <br /> Secondary Containment Testing RepQ#Npm HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST seconda;We S1n50W kAs. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form,x ritten test procedures, 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: 7-ve MPoov I Date of Testing: le <br /> Facility Address: 3 ,900 WC 7",- W,�P roe <br /> Facility Contact: Lay dde ` Phtine: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: r`G'/rZ�� .2�� �/' � ,R✓ J <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: 1_ %AeCT) License Number: . <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass F ' Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested A <br /> lade <br /> s ( ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ;L✓ U / i c ❑ ❑ r I ❑ ❑ <br /> El <br /> SU i r ❑ ❑ I ❑ ❑ <br /> 5111 2 i '_ f ❑ ❑ ❑ ❑ i ❑ ❑ <br /> G / I I ❑ _ El <br /> I El El(,� C _ ❑ _ [I I u _ 011 <br /> :7] ❑ ❑ ❑ I ❑ `! ❑ ❑ <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 TESTLtiG <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> R jG 2 r d 4.me(0/ rd . <br /> Technician's Signature: Date:—/ d 1 � <br />