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0 <br />SWRCB, January 2002 Page 4— of <br />Secondary Containment Testing Report Form <br />This form is imtended for use by contractors performing periodic testing of USP secondary containment systems. Use t ie <br />appropriate pages of this form to report results far all coitiponrents tested The completed form, written test procedures, and <br />printoutsfrom tests flfupplieable), should bepeovlded to thefactlity owner/operatorfor submittal to the local reguldtoryagency. <br />1. FACILITY INFORMATION <br />Facility Name: M Date of Testis f t 2 o'Z <br />Facility Address: Z�1 � � � �(" G � <br />Facility Contact: W t4, yr - Phone: <br />Dam Local Agency was Notifiedof-Testing: r I &I 07— <br />Name <br />zName of Local Agency Inspector ((f'present during testing): <br />Z. TESTING CONTRACTOR INFORMATION <br />Technician Conducting Test.,. <br />Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: • e License Number; q1 16 S'S <br />M2nar4ctarer TrRhd= <br />Manufacturer Component(s) Date Trait&g Expires <br />h T�" <br />3. SUINARY OF TEST RESULTS <br />EMI <br />OWN <br />mmm� <br />�a■■i� NMI== <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests. <br />G(�uw�z <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, t is stated in skis document are accurate and In full compliance,wMk legal requirements <br />Technician's Signature: Date: P Z 'z <br />s r 0� <br />