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SWRCB, January 2002 Page G of 4-- <br />' Secondary Conta ent Testing'I2egort Forlo <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: AS Date of Testing: 4 111 ay <br />Facility Address: 133c7 E. t.> yr i-rr 1-4 <br />Facility Contact: Ke 411,3 <br />M <br />Date Local Agen cy Was Notified of Testing <br />Name of Local Agency Inspector (rfpresent during testing): <br />2. TESTINO'CONTRACTOR INFORMATION: <br />Company Name: <br />Technician Conducting Test: per,_ &JI KA f1l4) <br />Credentials: 0 CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type:. License Number: a ..; 16-74 <br />Manufacturer TraininLy <br />Manufacturer Comr)onent(-1 Date TraininLy Expires . <br />Z QTTr fMa+'QV nF TFi'.RT !?FRITI,7'9 <br />Component <br />Component0 <br />M <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 lega requirements <br />Technician's Signatu Date: l 7 QJ <br />44o tic) <br />L- e (�``� <br />