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S WRCB, January 2002 0 *CEIVED <br />Page I— of <br />Secondary Containment Testing Re#M ForoB <br />This form is intended for use by contractors performing periodic testing of UST se' 4 ms. Use the <br />appropriate pages of this farm to report results for all components tested The compl �S ioUlsprocedures, and <br />printoutsfrom tests (if applicable), should be provided to thefacility owner/operatorfor su mittalocal regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: M e I �� K e a �S ���-✓a� uew. ��n � , <br />Date of Testing: 3 0.6 <br />Facility Address: M v 4q :.44--,B L v ,�- , 1'' &4 d --e et Cat. tet S -;34 <br />Facility Contact: V-- T� P Phone: o-?) <br />Date Local Agency Was Notified of Testing : Z t 0 K <br />Name of Local Agency Inspector (rfpresent during testing): <br />2. TESTING CONTRACTOR INFORMATIONMAR 13 <br />ao <br />I <br />Company Name: R- � D C c�,^„ r a,,,�c e.'�. s A--YL14E NVI R <br />Technician Conducting Test: � �,^^ cc we i rttiv <br />4'r, -V j�;PER ITISEWeES <br />Credentials: 0 CSLB Licensed Contractor <br />WRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: q© --t 12.0 <br />Manufacturer Training <br />Com onent s Date Training E ires <br />Ell <br />Component <br />Component <br />Ell <br />oo� <br />-4 <br />=ora <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 Inthis document are accurate and in full compliance with legal requirements <br />Technician's Signa �� c K r.�,.w _ Date: 13 /0-6 <br />