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� <br />SCB, January 2002 Page — of <br />Secondary Containment Testing Report Fox <br />This form is lnrended for use by contractors perfOrmisrg periodic testing of UST seeonc&tty containment systems. Use the <br />appropelate pages of rhts form to report results for all components tested The completed form, written test procedures, and <br />printouts front tests (if applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br />1. FACILITY MORMATION <br />Facility Name: f1 C& ww ti'1 Date of Testing: ( t7 4 -F-- <br />Facility <br />Facility Address: Z. !i �, !� wJ - ..�. GOf <br />(Facility Contact' Phone: <br />Date Local A&MY Was Notified of esting; ju &2 u <br />-7Rame of Local Agency Inspector (rfpresew during teiting): <br />3. SUMURY OF TEST RESULTS <br />MK= <br />L . <br />If hydrostati,� testing was cribe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICL414 RESPONSIBLE FOR CONDUCTING THIS 77STIN <br />To the best of my knowledge, tae fach thk dacummt are accurate and In full compl&tnce wltltlr legal regttlremenif <br />Technician's Signature:_Date' U) �� — <br />