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SWRCB, January 2W2 page t of <br />Secondary Containment Testing Report Form <br />This form is !mended for use by contractors performing periodic testing of USTsecondwy containment systems. Use the <br />qWWrlatepages of thisform to report results for all coqwnews tested M completed form, written test procedures, and <br />printouts from tests (Vapplicable), should be provided to thefactito, ownerlopwatorfor submittal to the local regulatory agav-7 <br />Date Local Agenc r Was Notified of Testing: <br />U1 <br />9 <br />ITechtdcian Conducting Test: jr=$.SgNg2�� I <br />.Credentials: 3 CSLB Licensed Contractor a SWRCB Licensed Tank Tester <br />License Type: B C61 0 A HAZ License Num 304147 <br />cl <br />SEP 10 2glo <br />WM <br />3. SUMMARY OF TEST RESULTS <br />MOM" <br />mmm <br />MW <br />mm" <br />om <br />on <br />OM <br />On <br />mom <br />no= <br />omm <br />000NOMMM <br />if hydrostatic testing was perf6ruied, describe what was done with ft water after completion of too: <br />C7 - -Soh-45 <br />'514 <br />CERTIFICATLY <br />OF Tf,'�HN <br />ICIAN ]RESPONSIBLE FOR CONDUCTING THIS TISTING <br />we acewwo and In AN emwPilance with k8al requirements <br />Date: -71(0 <br />SEP 10 2glo <br />WM <br />