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11 <br />SWRCB, January 2002 <br />Page _ of <br />Secondary Containment Testing ReportLF2r--Iz) tq <br />]ROG-9 <br />This form is intended for use by contraciors performing periodic testing of UST secondary containment e <br />appropriate pages of this form to report results for all components tested The completed form, wt r res, <br />printouts from testy (if applicabie), should be prodded to the facility ownerloperator for submitter <br />ptohetalTato4 agency. <br />ENVIRONMENT NEAT TP <br />1. FACILITY INFORMATION n -. --- <br />Facility Name: ,�j L,4A�V Cj(k�6— I Date of <br />Facility Address: e4 3 1 vii , <br />Facility Contact:I Phone: 7- --z.-3 t4 q <br />,idkvk <br />Date Local Agency Was Notified of Testing : <br />Name of Local Agency Inspector (if present &mW testing}: <br />0 <br />Fjzcw It �l 1i <br />Company Name: Clk--\ n=�M C�i I c2i (Z:;� nry 7—C" -\\Z- - A-P-6,nc, <br />Technician Conducting Test: j <br />Credentials: CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: (3C0\.k6PU I License Number: <br />PV enfacturer Training <br />Date <br />515,W11499 <br />Component <br />Pass Fail <br />Not Repairs <br />Tested Made Component Pass <br />Fail <br />Not <br />Tested <br />Repair <br />Mades <br />41- <br />0 <br />0 <br />!-111 <br />0 <br />0 <br />0 <br />n <br />D <br />0 <br />J--pj,-j <br />0 <br />If hydrostatic testing was performed, describe what was done with the water after completion, of tests: <br />CER. CATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING TEI[S TESTTNG <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: Z- <br />-2 <br />/ I <br />