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SWRCB, January 2002 <br />Page / of ?— <br />Secondary <br />Secondary Conta ent Testinb'Report Form <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 regulato,y agency. <br />1. FACILITY INFORMATION <br />Facility Name: JA5 Date of Testing: 9 / 7 /a5 <br />Facility Address: ► 33v C. Oscvv� ITEd A' <br />Facility Contact: Je 113 Phone <br />Date Local Agency Was Notified of Testing : d a - Z9 .0 5 <br />Name of Local Agency Inspector (rfpresent during testing): <br />/'1 WTT71 . nmlln TATL'nDM A TTnN <br />G. 1 --- -- <br />Com an Name: --- <br />Technician Conducting Test: „p. A^C <br />Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type:. License Number: G+ 6 -7 <br />Manufacturer Training <br />Manufacturer Componentfsl Date Training <br />,,. — s , r.t7 nr. mT. CST nL�CT..Tf TC" <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 knoWede, tine facts stated in this document are accurate and in full compliance with lega re ui <br />brements <br />Technician's Signa �i Date: a,5" <br />. <br />dw <br />RepairsMadeM0MWE <br />Component <br />M, <br />r <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 knoWede, tine facts stated in this document are accurate and in full compliance with lega re ui <br />brements <br />Technician's Signa �i Date: a,5" <br />