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SWRCB, January 2002 Page of_ <br />f Secondary Con tai ent T'esting*R.eport Form <br />This form is intended for use by contractors performing periodic testing of UST secondary 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 ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION z / <br />Facility Name: , D 67WeAkk I Date of Testing: <br />Facility Address: 17-l S. rA At% Lt I 5TOC-e rro rJ 02-- <br />Facility Contact: <br />W15 -T Phone: 6 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (tfpresent during testing): <br />7 mV cTW0-'rnNTR A rTOR INFORMATION: <br />� c�nc�� A �v d1Ta' T1G'.ST RF.�T•Tf .'T'.�, <br />Component Component <br />MW - <br />MM <br />■ <br />AA <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATIO_NRFTE ICIA.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my Irno We fa s st d in this document are accurate and in full complianceWIhlegequirements <br />Date:Technician's Signature: <br />