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SWRCB, January 2002 <br />Page of <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 tested. 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: , c U t x7 <br />Date of Testing: <br />Facility Address: 7 fi 1 C_` f `� ,,„ j I' � - ,o � <br />�; � � �. 5 � <br />Facility Contact: C 4 uo d <br />Phone: 4. <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (ifpresent during testing): <br />2_ TFSTTNO*'CONTRACTOR INFORMATION <br />'A_ CTTMMARV€ F I1V9TRESULTS <br />Component 'Component <br />Mom <br />Mom <br />�--_ <br />00� <br />000 <br />00 <br />If hydrostatic testing w�ya�s per -formed, describe what was done with the water after completion of tests: <br />C <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 le; al requirements <br />/ <br />Technician's Signature:r- Date: <br />