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FROM (WED) SEP 13 2006 18' 4/ST. 18:03/No. 6843597367 P 2 <br />j SWRCB, January 2002 Page of a4 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of thio form to report results -for all components tested. rhe completed form, written test procedures, and <br />i printouts from tests (if applicable), should be provided to the faetlity owner/operator for submittal to the local regulatory agency. <br />E <br />u <br />Facility Name: adf 91 Date of Testing: <br />Facility ,Address: 0 <br />Facility Contact: Iphone; <br />Date Local Agency Was Notified of Testing: 1101 -ho Ar_: <br />Name of Local Agency Tnspector (if present Aurin testi g): <br />if hydrostatic testing was perfortned, describe what was done with the water after comaletion of oasts: <br />CERTIFICATJON OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my keno e, t f stated in this document are accurate and in fall compliance with legal requirements <br />Technician's Signature; Date:. Q �+� <br />nn 1 IT <br />M11—am—mm <br />TJWMAW-Wfllmmmmm� <br />lam= <br />Moog <br />MMOMM <br />if hydrostatic testing was perfortned, describe what was done with the water after comaletion of oasts: <br />CERTIFICATJON OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my keno e, t f stated in this document are accurate and in fall compliance with legal requirements <br />Technician's Signature; Date:. Q �+� <br />