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May 04 06 11:27a (2nQJ 794-0112 P.6 <br />SWRC13, January 2002 -49 Page of <br />Secondary Containment Testing Form <br />rhzsfc,rmisintended for use 4yc,pn&,aclor-Tperfol,mingperiodic te-TtingofMT.vocoi7dmyconfaz,ffmcntsystems. Use the <br />appropriate of thisform to report results for all components tested The completed form. written test procedures, and <br />pr#jjoutsfrom tarts (if applicable), should be provided to thefacility ownerloperatorfor submittal to the local regulatory agency. <br />1. FACMITY INFORMATION ' . f / <br />Facility Name: Cog. ve44'.P-> I Date of Tc.-Aing. 7 1.*!r <br />Facility Address.p 12Xr7-1--rPfAA3 4 &, <br />-e4 .g>b; CA <br />- <br />Facility Contact `7o- Aj Y Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Impactor (rfPrexent during testing): <br />2. TESTING'CONTRACTOR WOKWU11ON: <br />Comi3any Name: <br />Technician Conducting Test A&b& MIA&A0 <br />Credentials: 0 CSLB Licensed Contractor _8!WRCB Licensed Tank Tester <br />License Type: I LicenseNwnber -o TV -7,Z <br />MgLnuf9gUMr jr2jElp <br />Manufacturer Com aws) Date TraintLEMices _ <br />3. SUAUVEARY OF TEST <br />REWLTS <br />awl <br />If hydrostmtic tcr.tmg was performed, dcxc;jbc what was done with the water after completion of tests: <br />F -- 11111�! <br />11 19A <br />Min_ <br />li ZWE I <br />CgRTIFICATION OF TECHNICIAN RESPONSIDLE FOR COND17CTING THIS TESTING <br />710 ilia baytof my Irnmyledge, th a stated in this docanzeni are acchate and in Putt compliance with le; JiIre 4uirements <br />"'a <br />Ih (Cjl"d �fta r' <br />Tochniclan's Stmaturc. <br />