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11 L I UL IU. L Inco I,AVH1 nLA11 VVIVJI11U1L11V1V rUL <br />SV RC13, January 2002 <br />i� page of <br />Secondary Containment Testing Report Form <br />Aisform is intended for use by contractors performing periodic testing of USTsecondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completedform, written test procedures, and <br />printouts from tests (fapplicable), should be provided to the facility owner/operator for .submittal to the local regulatory agency. <br />1. FACELUY INFORMATION <br />Facility Nance: (.0 A wL Datt o£T j f. <br />Facility Address: at zK e L,q <br />Facility contact: ui A trt t're hone: <br />Date Local Agency Was Notified of 146sting : 4 <br />Name of Local Agency Inspector (f present during t n,g%: <br />2. TESTING CONTRACTOR INFORMATION <br />co No . <br />Technician Conducting Test (6s(, <br />Credentials: CSLB Lktaed SWRCB Licensed Tank Tester <br />Lioemse Type: A Q Cc- License Number: cit[ <br />11Laufneturer Trwinin¢ <br />Nianufachm s Date Tminin P-Xpircs <br />U �.. <br />3. SUMMMY OF TEST RMSULTS <br />=MEN <br />mom <br />JLvj--_mmm_ --__ <br />If hydrostatic testing was performed, describe what was done with the water aflef/ompletio� of tests: <br />CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the cis stated In this document are accurate and In full compliance with legal requirements <br />Technician's Signature: Date: t l t <br />';e <br />