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�R <br />SWRCB, January 2002 ' ge _ of <br />Secondary Containment Testing Rei �+5 orm ��v7 <br />ira,�,,{`t�VA <br />This form is intended for use by contractors performing periodic testing of UST secon �, tilr(t �s Use the <br />appropriate pages of this form to report results for all components tested. The completed form,ft�xit7e stwo educes, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the loc2 l regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: e f 5-er" Date of Testing: 1 /I( - <br />Facility Address: n 313 (1J e&4- <br />Facility Contact: pit v r, 1 Phone: (2-U 474 3 1' <br />Date Local Agency Was Notified of Testing : 11It 1) <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: <br />Technician Conducting Test: 1 ' u w+ r`P.ff cit - <br />Credentials: D CRI B License Contractor RCB Licensed Tank Tester <br />License Type:�uvtLicense Number: 49—/1 <br />Manufacturer Training <br />Manufacturer <br />►IlliK;11 <br />Date Traini <br />r <br />®®win' <br />Component <br />D000 <br />mom <br />mmoo <br />mmoo <br />omo <br />� <br />0mm <br />mmoo <br />moo <br />j <br />mmooi <br />mm <br />: <br />o <br />onoo <br />aoot� <br />mmoo <br />If hydrostatic testing was performed, /describe what was done with the water after completion of tests: <br />t®® ,V-0.,lChi 1-4 %% l�fi i�,_,... /v ---- . ®mow J— <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledg they acts stated in this docu nt are accurate and in full compliance with legal requirements <br />Technician's Signatur . Date: <br />