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e SWRCB,�Tanuary 2002 Page of 7 <br />Secondary Coni r esiing Report Form <br />This form is intendedfor use by contractors pSAVA'b riodic;tqqjgjof USTsecondary containment systems. Use the <br />appropriate pages of this form to report results fWRl diff e <s;teged. 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.:bency. <br />1M W.T81 I IN 11041IU 5) 6,13 r4VF 10 <br />Facility Name: W-l-er L;Autrtc3Date of Testing: <br />Facility Address: EA -� A7 , 'I's . S" <br />Facility Contact: L L G Phone: -0 4 3— <br />Date Local Agency Was Notified of Testing: O <br />Name of Local Agency Inspector (fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:17 75 <br />Technician Conducting Test. <br />Credentials: ❑ CSLB Licensed Contractor WRCB Licensed Tank Tester <br />License Type. - T -e4,.. V License Number: 170 -1 x-1_0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />,d D - F <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this cument are accurate and in full compliance with legal requirements <br />r <br />l Z <br />U <br />Technician's Signature Date: _ <br />EM <br />'EM <br />, <br />mom <br />W12 MMI <br />Mi <br />■ <br />■ <br />MMM' <br />��=. <br />I 1 <br />��M <br />M� <br />IP, <br />K I <br />MMM <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />,d D - F <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this cument are accurate and in full compliance with legal requirements <br />r <br />l Z <br />U <br />Technician's Signature Date: _ <br />