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SWRCB, January 2002 '. Y �y <br />„ t r Paget' f L <br />Secondary Containment Testing Report F* <br />This form is intended for use by contractors performing periodic testing of UST secondary cog ent systems. Use Phe <br />appropriate pages of this form to report results for all components tested. The completed form, lYf F#ures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for sub f, -l.®'. #4k foe&I•egulatory agency, <br />1 F A!`TT iTV iNL`l1DA,g a mTnaT <br />Facility Name: '&,eO - e 14_ i 5 �t'tC.t mer Date of Testing: <br />Facility Address: Z S �,1c _Dy_ j, c S 2 U <br />Facility Contact: -14,--- t k < , A-^ -Phone(-2-4 Q <br />Date Local Agency Was Notified of Testing: Z p <br />Name of Local Agency Inspector (ifpresent during testing): <br />2_ TTQTYMi-irn?V'rD A rrnD TI%TV IMIL r e •s.r�wr <br />Company Name: j ` q,A,+_ c a. -e S % V -- <br />--Technician <br />Technician Conducting Test: -5.0--I <br />Credentials: ❑ CSLB Licensed ontractor <br />., WRCB Licensed Tank Tester <br />License Type: �-� <br />License Number: q1�61("UGGS <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) Date Training Ex ires <br />'t_ QiTMMADV n 1rrQ'T DVQ1FTT me <br />Component <br />Component <br />0, <br />oa�scs <br />.� <br />soo <br />wm=© <br />DOM <br />Brom <br />I Ma <br />soo <br />mom <br />sacs® <br />ssa <br />sorsa <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN R PONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In thls d cu ni are accurate and in full compliance with legal requirements <br />Technician's Signature _- ,�.,ti �..,. - Date: <br />C 1 <br />