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SWRCB, January 2002 9 0 P J of Secondary Containment Testing Repo This form is intended for use by contractors performing periodic testing of ULVSTsecondary co t system the appropriate pages of this form to report results for all components tested The completed form, writt eA o applicable), shpures, "d printouts from tests (if , q�� Wd be -provided to the owner/operator submittal 4 local r j;Wagency. 1. FACILITY INFORMATION Facility Name: Vv,,'\j -J',!' Date of Testing2tj9 Facility Address: v q e�' Facility Contact: v 6 S t" U-- I Phone- 1-" ` 7 V (,I Date Local Agency Was Notified of Testing: J (TI Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Technician Conducting Test:' -11'21 Credentials: 0 CSLB Licensed Contractor R SWRCB Licensed Tank Tester License Type: -,f y- License Number: `f i') I Manufacturer Training Manufacturer Component(s) Date Training Expires If hydrostatic testing was performed, describe what was done with the water after completion of tests: 7 1 j r CERTIFICATION OF TECHNICIAN -RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, Phe facts stated in this -document are accurate and in full compliance with legal requirements Fechnician's SigndtLffe: Date: IM, M F-77771 � � Component If hydrostatic testing was performed, describe what was done with the water after completion of tests: 7 1 j r CERTIFICATION OF TECHNICIAN -RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, Phe facts stated in this -document are accurate and in full compliance with legal requirements Fechnician's SigndtLffe: Date: �000 aoc�o �000 0000 o00 0000 o00 0000 �aoo; raao�■ �o©a ©000 ©o© oa©o Baa©o© o®© , -.� � �-_-___ _ .� _ _®®� _ _. _._ _ __ ________ _ _ __©__.moo If hydrostatic testing was performed, describe what was done with the water after completion of tests: 7 1 j r CERTIFICATION OF TECHNICIAN -RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, Phe facts stated in this -document are accurate and in full compliance with legal requirements Fechnician's SigndtLffe: Date: