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A <br />SWRCB, January 2002 FEB 0 5 I' age 1 of <br />Secondary Containment Testing ReportA, <br />This form is intended for use by contractors performing periodic testing of UST secondary cont44hiW�wk-j Pe the <br />appropriate pages ofthis form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />xxej I M V VA <br />Facility Name: (A uVe hro EL wv Date of Testing: <br />Facility Address: -6 <br />P j goi vv� PL4 0, te UG4Aj C 1, fU'-k <br />Facility Contact: k I L -i" 1Q,1 " 5 --- I Phone: <br />Date Local Agency Was Notified of Testing: I Z4 , 1666 <br />Name of Local Agency Inspector (i(present during testing):' <br />ON P&MV-6315 V "T.Tal MQ AEE�R� <br />Company Name:iiq viU & 161&,-ew;;-I. <br />T,1-1 - <br />Technician Conducting Test: <br />Credentials: 0 CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: 41 <br />License Number: <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />MM <br />, M,7 <br />Mow - <br />If hydrostatic testing was performed, describe what was done with the dater after completion of tests: <br />I - - <br />- i.% K <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledr the facts stated document ar accurate and in full compliance with legal requirements <br />Technician's Signature:- Date: /41 /10 <br />