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Mar 17 04 01:25p RR` DER SINGH 209 1 0142 p.2 0 4P S RCB, January 2002 Page of Secondary Containment Testing Report Form , 772is farm is intended for use by contractors ae+formtngperiodic testing of USTsecondary containmentsystems'. Use•the appropriate pages of this form to report results for all components rested The completed form, wrtuen tes7 procedures, and printouts from tests (if applicable), should be provided to the facility ownen,bperator for submittal to the local reguiatory agency. 1. FACILITY INFORMATION Date of Testing: j Facility Name t .3 i Sc� ,e :. (' '�i i L' - FacAity Address: y Th, Il `ti 4► 1'1✓ }� Facility Contact: j ' �_ L ?6, °�Y Phone: y Z - Z-> Li `i Date Local Agency Was Notified of Testing arne of Local Agency Inspector (if present during Testing) 1: Company Mame: Technician Conducting Test: —kz--, ' Credentials: X CSLB Licensed Contractor C SWRCB Licensed Tani: Tester License Type: L `�;�\ j acture• License Number: ldanufactnrer Traentzt component(s) Date Traetun E. fres E Repairs ! Pass Fad Tested Made 021 ifhudrostatic testing was performed, describe what was done with the water after completion of tests: CERTMCATION OF TECHNICIAN RESPONSIBLE FOR CON-1WCTING THIS TESTING To the best of n1j, knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Date: Technician's Sitature: __ J. ZvivrU.u' NotI RepairsCarnponeat Pass iFaii' Not E Repairs ! Pass Fad Tested Made Tested Made _ J L gg ED ❑ 0 ❑ Ej, � r [ j 1 L ❑ C ' u 1-j L, J t i r, ��--�� ijEI iJ D L: i 7 u L D ifhudrostatic testing was performed, describe what was done with the water after completion of tests: CERTMCATION OF TECHNICIAN RESPONSIBLE FOR CON-1WCTING THIS TESTING To the best of n1j, knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Date: Technician's Sitature: __