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* S WRCB, January 2002 0 RECMV\414� of <br />Secondary Containment Testing Report For $ 3 2006 <br />This form is intended for use by contractors perforating periodic testing of UST secondary conta' Nd appropriate pages of thisform to report resultsfor all components tested Thecompleted form, <br />printouts from tests ftf applicable), should be provided to the facility owner/operator for submittal agency, <br />1. FACILITY INFORMATION <br />FL,� <br />Facility Name: N . t_ d _S 'p e ;moo k.e V. V„ 7U7,-, C_ IDate of Testing: 3 Z OfI- <br />Facility Address: g q q M e 5 5 l e 2d • La A-�\ wo G- `� 5- 3 3 0 <br />Facility Contact: Phone: v-1 9 S 2 -07 6 to <br />Date Local Agency Was Notified of Testing: u1V <br />Name of Local Agency Inspector (fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name. P, <br />Technician Conducting Test:' eK ' ; r,, ` Y <br />Credentials: D CSLB Licensed Contractor KSWRCB Licensed Tank Tester <br />License Type: T= V- License Number: <br />Manufacturer Training <br />Manufacturer Com onent s Date Training Expires <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />t c - --s+(ufd s�4l; <br />d <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 />Technician's Signature: Date: 3 L <br />Component <br />.'' <br />MMS` <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />t c - --s+(ufd s�4l; <br />d <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 />Technician's Signature: Date: 3 L <br />