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SWRCB, January 2002 <br />46 Page 6 of L <br />Secondary Containment 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 regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: eo A.) -rx?-Ae- 7Q / -S Date of Testing: 2 65 <br />Facility Address: IQ66 J.J l cAlf"N -r 95;Lo 6 <br />Facility Contact: p 0 Phone: -0:3-7— <br />Date Local Agency Was Notified of Testing: Oq b I o5 <br />Name of Local Agency Inspector (tf present during testing): <br />m,aomrArnl�nNTTlA!—MR MWORMATION: <br />Component <br />Component <br />ikepairs <br />Made <br />M <br />MAINNoME <br />� <br />MM_mom <br />_ <br />mom <br />�0 <br />II mom_: <br />No <br />�0no <br />ii�j <br />I <br />I <br />rlLnr;lir+ u,lhat was rine with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, tf$e facts stated in this document are accurate and in full compliance with lega require - ents <br />Technician's Signature: Date:_ <br />