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vv a� vv a+ av+..•+ +aa�m ua.atn v vawaatvva(VI,V IUL <br />SWIzCB, January 2003 <br />Page l of S <br />Secondary Containment Testing Report Form <br />This form is intended fOr tise by eaiTirctclors perforining 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 frwir tests (If applicable), should he provided to ►he facility owner/operator for submilial to the local regulatoi)l agency <br />10 • rrr T'ry TMVn1D M A T1f nM <br />Facility Name• _ I Date ofTestin : z. --1L _U' <br />Facility Address:2i4I %D }7 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency 111spee(0r (if present during testing): <br />.......>�..r .,n,.t.+ri • rTn7] rwimallD M A "nM <br />A. it X40 acv 4•Ya�a��c�vav _ _ �_____ <br />company Name: <br />Technician Conducting Test: <br />Credentials: -^CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: ig 14rjr.Ne 4 <br />License Number: ,Y #,t, <br />1,6 <br />Manufacturer <br />Mann acturer TEIp aing <br />Catn nent(s) Date Training Ex ires <br />T T' <br />a....n�� • nv d"%w lrr,•40,r T]CQTTV TC <br />mom <br />WTI rr, M— <br />C:CCC. ••••� <br />If hydrostatic testing was performed, describe what was done with the water atter <br />of LeSES: <br />CERTIFICATION OF TECHNICIAN RESPON91BLE FOR CONDUCTING THIS TESTING <br />Tii the best of IttY knowledge, the fdCts crated lit this docanvent are accurate and la fill etunplittace wigi legal reguireiuents <br />T'echnician's Signature: Date: 2-1�/r0"T <br />