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From: Franzen -Hill Inc. To: 12094683433 Page: 2/8 Date: 8/12/2011 8:34:56 AM <br />SWRCB, January 2002 Page of <br />Secondary Containment Testing Report Form <br />ThIsjoym is intended for use by contractors performing periodic testing of UST secondary cOntaftment systems: Use the <br />appropriate pages ofthis 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. FACELITY INFORMATION <br />Facili Name, -Date ciffestinW. <br />10 <br />Facility Address: <br />Facility Contact: Phone. ® <br />Date Local Agency Was Not ofTesting , /,06. ........ <br />--,,1r- - -------- <br />Name of Local Agency InVeCtOr _j <br />101 7�21? R <br />- - --------- - <br />- <br />-------- <br />------- 11 <br />to M, <br />Licanse NUmbef- 304147 <br />MWMfSgjgrtr Tra <br />Manufacturer compoftent(0) <br />Date Trafn <br />CERTIFICATION OF TECHNICIAN RESPONSIALN FOR CONDUCTING THIS TESTING <br />To f1je best of my knowkike, Elle facts stated In tills document are accurate and infug complknee'With legal requirements <br />Technician's Slj;natur-Datr.____ 2_01L <br />W 1011�' <br />This fax was sent with GFI FAXmaker fax server. For more information, visit: hftp://www.gfi.com <br />