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s ar SWR`;B, January 2002 Page of� <br />SecondaryContainment Testing ���� <br />g eort For 14 <br />This form is intended for use by contractors performing periodic testing of UST secondary cont' en s the <br />appropriate pages of this form to report results for all components tested. The completed form, rote ,gs, and <br />rrntouts om testsi a #cable <br />_(f PP. � )_should be.provided to.the;l'aciliiy owner/operator. forsubmitt �`,VWj latory agency.-- <br />1. FACILITY iNFOR ATION /` cr 1,iBr� A TS! <br />Facility Name: &ty V_Uj o 6 1 V1 ✓o - - —_ _ - Date of Testing: <br />Facility Address: � fo t i O pa� e imw e V' : 4 �' e <br />Facility Contact: '�c�VIL - __ o 'i�� Phone (� Z <br />S -go <br />Date Local Agency Was Notified of Testing : Z v <br />Name of Local Agency Inspector (rf present during testing): <br />3. SUMMARY OF TEST RESULTS <br />Component <br />jm� <br />Component <br />•���,�� <br />� <br />cavo.: <br />ra000 <br />o00 <br />0000 <br />moon <br />mmoo <br />opo <br />a000 <br />o0o <br />mono <br />mmom■ <br />mmoo <br />Moo0 <br />mmm0 <br />000 <br />0000 <br />If hydrostats testing was performed, describe what was done with a w,Wjater after completion of tests: <br />o i C �(d,Q l� d r'"'. ..? '' �,�,,ror. T ^�' P '' � r �; �a y <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In tie ument araccurate and In full compliance with legal requirements <br />Technician's Signature _, _ _.� - Date: Z <br />L a <br />