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SWRCB, January 2002 <br />Page i of � <br />Secondary Contain nt Testinb'Report Form 9 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components testers The completed form, written 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: I<� fe �s Date of Testing: <br />Facility Address: a <br />Facility Contact: k Phone: �- <br />Date Local Agency Was Not d of Testing : �"7' —/ 2- _ b (�, <br />Name of Local Agency Inspector (tfpresent during testing): ,�� cr. rr- <br />TFCTM0-'r0NTRArT0R INFORMATION: <br />Component Component <br />momMMMM <br />0000 <br />000 <br />0000; <br />MMMM -oo <br />o <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 />E <br />r <br />Technician's Signature:_ ` - t Date: <br />