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SWR('II, Ju►tuary 2003 � Page I of Z <br />Secondary Containment Testing Report Form <br />This.l v'»i is intcnilddfor use by conlpaclors performing periodic lesting ojUST secondsty cuntainutenl syslen►s. Use the <br />c+ll„•, �l�riute l,ug��.+ ►�/lhly jour► in , epor! res►tltr fi>r cl! conrpr,nenrr tesred The completed form, tit�rilien test procedures, and <br />pri»t,>n►.vfi n,n tests (lf opplicable), should be provided to the facility owner/operatar for submitial to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facthly N.nnc, Date of Testing: <br />Facility <br />yAddress: Z y uC PoNnl,re pkv ►'� L <br />Facility Contact', t+✓av%sk.a. Pone: <br />rote Local Agency Was Notified f Testing-* 2,—,0&—b7, <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING ct <br />Company 14ame:1CCtr L4+n"*"+c+k6`% <br />Technician Conducting Test: J04%, <br />Credentials: X CSLB Licensed Contractor <br />License Type' A (A _ Age, H t4 <br />TION <br />SWRCi3 Licensed Tank Tester <br />License Number: 41( OS3 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THiS TESTING <br />To the best of lily knowledge, t1 acts «red In t/rls rincutnarrt «re acrnr«rr unit !u full colnpllarice with legal reyulrentents <br />Technician's Signature: Date: Z -71t03 <br />