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�C 6— 0 <br />SWRCB, January 2002 � �"� ���Page -L-of <br />Secondary Containment Testing.:ReykAvorm <br />' This form is intended for use by contractors performing periodic testing ofl. seco9 440 r,&" aent systems. Use the <br />appropriate pages of this farm to report results for all components tested },eoTP(gt'�ritten test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/o 'r'd6r for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: o L 3 it o Ys Date of Testing: 1 O (� <br />Facility Address:c.rv ir x�_, -o 5 <br />Facility Contact: 4- , },-, .e -e <br />Phone: -2-o 44 j 1 <br />Date Local Agency Was Notified of Testing: 1 I t cJ U S <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />(;.P�; cev V�e. 461Vxar..e, by i2 I !°� dJ�f` <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: � ,.,.- vv��--� � � ti., �e.�.�-(`Date: <br />Component <br />®® <br />r <br />aur■;mom <br />M <br />UP�- <br />omm�� <br />�' <br />mool <br />mmoo <br />MOM <br />000� <br />moo <br />omoo <br />_ <br />mom <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />(;.P�; cev V�e. 461Vxar..e, by i2 I !°� dJ�f` <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: � ,.,.- vv��--� � � ti., �e.�.�-(`Date: <br />