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. S WRCB, January 2002 Secondfy <br />1 of <br />C `V'E <br />Containment Testing a ort o m <br />This form is intended for use by contractors performing periodic testing of UST secondary containmen - n1s. 7U <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 theAcility-owner/operator for submittalz�IM 'ncy. <br />1. FACILITY ® TION PERMIT/SEM • <br />Facility Name: F o, y �4_w b e), I U �j � e ✓ 0Date of Testing; <br />Facility Address: ��� r.,<sAnvv�e.V' t) Ic rrv�E� - <br />Facility Contact: "�c`t t —�—@ Phone:(- <br />Date Local Agency Was Notified of Testing ; Z p <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TF,�TiNf ['(1NT72 ®!`Tl1D mr�nDA r e mteasT <br />k L . ! a . r <br />Component <br />Component <br />Man <br />o0o <br />aaoo <br />o00 <br />Dada <br />it nyaProstati testing was performed}, describe what ,pwas done withffie water after completion of tests: g <br />%'-G"J .t.R 1 � � !-+ f 'L� ��t ` --- � �C...`'"�°��•��E::; - �'a�" d�t•�.I � ws � � �".�.�ss e � : dr,.s. ro± "� /�":. b ....ale <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in t ument are, accurate and in full compliance with legal requirements <br />Technician's Signature Date: Z- 0 <br />