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03-12-03 03:22PM FROM KEgONSTRUCTION <br />SWR, ' . January'2002 <br />Secondary Containment Testing Report Form <br />P02 <br />Page — of!„-, <br />This,l o -in is inleia,led for Ilse by contractors performing periodic testing of UST secondary containment systems. Use the <br />appy, 11 a'late pagct of this form to report results for all components tested. The completed form, written test procedures, and <br />printj , is f -on, tc•5Lr(if applicable), should be provided to the facility ownerloperator for submittal to ilia local regulatory agency. <br />1. FACILITY INFORMATION <br />Date of Testin -5111/o <br />Faciiily Name: ,�,t�14ll WWt _-�(� �� 7 �=,—t= <br />Facility Address; -�.w �o"� bwr'�a � <br />tacilily Contact: Wa <br />y ut �r�ft Phone: <br />Dat.: imcal Agency Was NotitSed fTesting : :$/I i3 <br />Name of Local Agency inspector ('{%'present during testin9): <br />2, TESTING CONTRACTOR INFORMATION <br />Cotnpany Name .IIA N --- - <br />1'echnician Conducting'1'est: Q,,r ,n 0!+0+ <br />Credentials: XCSL8 Licensed Contractor SWRCS Licensed Tank Tester <br />License Type: fl e."t. ! G _ License Number: q%1 #J 3 <br />Manufacttner component(s) Date <br />If hydrostatic testing was performed, describe what was done with the water atter completion or tests: <br />Ci wnFIC..ATION OF TFCIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />Tia the hest of my knowledge, theA Lt stttletl ht iltic doettttteNt are accurttte and In fill/ cotnptlance with legal requirc'ntettts <br />'I'ecilnician's Signature, <br />