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SWRCB, January 2002 Wage i of .1--, <br />Sry <br />econda Contai ent Testing Report Form <br />" <br />This form is intended for use by contractors performing periodic testing of UST secondmy containment systems. Use the <br />appropriate pages of this 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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name L%Q �.X® s Date of Testing: f ef105- <br />Facility <br />0 -Facility Address:6�2 � -�oc�e ioe.� Q52- <br />Facility Contact: C-� Phone: -7pf- �{ 1 t <br />Date Local Agency Was Notified of Testing: 0 8 _ z 9 , <br />Name of Local Agency Inspector (if present during testing): <br />2 TESTIlYO'CONTRACTOR INFORMATION <br />Com an Name: 5- <br />Technician Conducting Test: <br />Credentials: O CSLB Licensed Contractor SWRCB Licen.�ed Tank Tester <br />License Type:. License Number: <br />Manufacturer Training <br />Manufacturer Component(-) Date <br />1 btir rn Kx x A 7D'gJ tri rr'V Q r D V QTTI .`j' <br />Tfl...A nctnt;c tP-zt;ncr wnc nerformed, 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 acts stated in this document are accurate and in full compliance with legal requir menu <br />Technician's Signature* Date: <br />Component <br />Component <br />�M== <br />r` VA <br />����■� <br />Tfl...A nctnt;c tP-zt;ncr wnc nerformed, 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 acts stated in this document are accurate and in full compliance with legal requir menu <br />Technician's Signature* Date: <br />