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SWRCB, January 2002 Page 4_ of 4 <br />s <br />Secondary Containment Testing Report Form <br />Tris foray is !»tended for use by contractors performing periodic testing of LlST'secondwy containment systems, Use the <br />appropriate pages of thisfarm to report results for all components tested, The completed form, written test procedures, and <br />printouts from tests f f applicable), should be pr'ovtded to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACEMY INFORMATILON <br />Facility Name: JK4A1 Am ftl I Date of T : 1 o7 - <br />Facility Address: 7-41 x v , he A,.. S y Pka -4 A <br />Facility Contact: (A,% t. - v CIL II Phone: <br />Date Local Agency Was Notified o esting : a a a pZ <br />Name of Local Agency InsPector f jfPment during tasting): <br />3. SUMMARY OF TEST RESULTS <br />Man <br />mom= <br />If hydrostatic testing Was perfomed, describe what was done with the water after completion of tests. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TES'T'ING <br />To Ura best of my knowledge, t u stated lir this documenr are accurate and to fall cornpllance,with legal requirements <br />Technician's Sigmture: pate: t'1 2't_ -�• <br />f <br />