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S WRCB, January 2002 ? L J' i ` , Mage of 1 <br />Secondary Containment Testing a ort , - r <br />This form is intended for use by contractors performing periodic testing of UST secondacontainment systems. Use the <br />appropriate pages of this form to report results for all components tested The complete}i+i ; '(iJd. duces, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for s _ I(F,Px 1 , /�s 'Ve latory. agency. <br />1. FACILITY INFORMATION <br />Facility Name:c,.,ry-,,ja Date of Testing: <br />Facility Address:' b 1 Wts J- " ex M VA -e, , La e S S Zo <br />Facility Contact: -7T -u, ABY S �L -� = Phone: Zd q S Z - - '-7 4) <br />Date Local Agency Was Notified of Testing: (U 2— D , - <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Nam1 ; -1-- 5 11 <br />Technician Conducting Test:q,,,ny,� l I D^ " ,,, V. - <br />Credentials: 0 CSLB Licensed Contractor kSWRCB Licensed Tank Tester <br />License Type-`�g License Number: o — b l f� <br />Manufacturer Training <br />Manufacturer Com onen s Date Training Exnires <br />1 <br />Component <br />Component <br />0 <br />FEW fflma�m <br />WE La. <br />o00 <br />0a�o <br />.. <br />��000 <br />000Q <br />r.�do <br />noc�o <br />it nyarostatic testing was performed, describe what was done with the water after completion of tests: <br />FT - <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated int document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 'Z J <br />