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SWRCB, January 2002 Page -T—.f <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic t-viring of UST secondary containment systems. Use the <br />appropriate pages ofthis form to report results for all components tested. The completedform; written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owneMAV4+1 suAMMM 03he local regulatory agency. <br />1. FACILITY INFORMATIQ <br />NJ I C 11 j x I <br />Facility Name: 4A-<_v-Lce> L_ ) cxu o �s Vitkm I S 0 <br />Facility Address: 2-,5 ( 2_ (A),RA_,e.y-Cr o0 "�15tfd'—o I I IL11 I <br />Facility Contact: 4W*%, V__ 5,k Phone: (-2-o-7 ) 44�3_ qjj <br />Date Local Agency Was Notified of Testing: <br />Name -of Local Agency Inspector (ii(preseiat during testing): <br />Component <br />airs'[ <br />Component <br />mill)r1ao�,�� <br />000 <br />�..�. � ►� <br />ago <br />�o�n <br />If hydrostatic testing was-06rfonnid, describe what Was done with the water after completion of tests: <br />1411 v n f;.f,_,1 e--1 Ve cov-9 7-;- fc-t' � <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To lite best of my knowledge, the facts stated In t1j' document are accurate and in full compliance with legal requirements <br />Technician's Signature: <br />Date: <br />