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FEB.25.2003 10:47AM SCOTT CO NO.615 *30/40 — <br />$WRCB; Januuty 2002 <br />Secondary Containment Testing egort Form <br />This form us intended for use by contractors pmf- orr.Mgperiodic resting of USTseca eontainmcnt sysler es. Use the <br />appropriate pages of this form to report results for all components tested The completed form, Wratten test procgures, and <br />printouts frAm tests (rjapplieable), should bepr/o�vy/� <br />i}ded to thefacility ownee/r'lo�p7erator for submittal to the local regulatory agency, <br />1. FAITY <br />Facility Name: Date of Testing! 4 <br />Facility Address: -�-u 1plarr'CE, <br />Facility Contact: <br />Dale Local Agency Was AlotifiEd of Testing, f <br />Name of Local Agency Inspector (If present during tafing ): V,7- <br />11 AyarOMuc testing WAS peri®rmed, describe ghat was dome wish the water r completion of tests. <br />1 t ►., <br />LE <br />TIFICATION OF TFCIMCLkN ONSrBFoil CONDUCTING THIS TESTING <br />the best of tray knowledge, the facts stated in thus do tare accurate and in full compliance with legal requiretrteratr <br />Teebnician's Signature, Date:C, -QX'"t. <br />