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.� Cv <br /> �U1 <br /> S WR CB,January 2002 �• Ui] <br /> IJ iL <br /> Secondary Containment Testing Report_FoM <br /> This form is intended for use by contractors performingperiodic testingo UST s t n ems. ' e t¢e7 2008 <br /> f ' . R d <br /> appropriate pages of this form to report results for all components tested. The compP X , .; x�rs"°„nd <br /> �f ; <br /> printouts from tests(if applicable),should be provide 6o the facility owner/operator jb�i#IimYttb� �hL loca�' n <br /> 1. FACILITY INFORMATION <br /> Facility Name: C, L vi e Date of Testing: <br /> Facility Address: or4-V V, S <br /> Facility Contact: Cc,y-e Phone: 2U R _ (d 3,b <br /> Date Local Agency Was Notified of Testing: '7)-2-1Q,9 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: ,, <br /> Credentials: ❑CSLB Licensed Nntrnctor WRCB Licensed Tank Tester <br /> License Type: "'('G,,,,,,ke— -c S -- License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ovv,4\ AV <br /> vt w tA 10✓-Gwa ic..__ ❑ ❑ ❑ (j 0 � Z E� 0 0 ❑ <br /> Le :,1 , C\10 4.2- D 0 ❑ `� �, ❑ ❑ ❑ <br /> raj . 0 ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> 5e,,gvj,Jj. �' ; ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 El <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydros tic testing 4as performed,describe what was done with the water after completion of tests: <br /> 01 <br /> CERTIFICATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,t e facts stated i h document are accurate and in full compliance with legal.requirements <br /> ` 4 Q <br /> Technician's Signaturel✓ Date: ��J <br />