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SWRCB, January 2002 Page of <br />Secondary Containment Testing Report For <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. U <br />appropriate pages of this form to report results for all components tested The completed form, written test)�li e , t <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatpryr�r. <br />1. FACILTry INFO TION <br />[11 V) <br />Facility <br />Facilit <br />y Name: (G fQ. t CC— Date of Testing: �.�. , ( a L_ <br />Facility Address: Is -1 A). Lob i <br />Facility Contact: Phone: _ <br />Date Local Agency Was 14otified of Testing : <br />Name of Local Agency Inspector (if present during testing) : <br />Company Name: - c S --1-8 �� <br />Technician Conducting Test: ` A—KI <br />Credentials: JK CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: ' )V Lir C�b License Number: <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Component „MM <br />r r <br />� <br />fsr Component <br />MM <br />i <br />mom�'' <br />mom <br />�, <br />a©moo <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 1 �, OZ <br />