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hbya66m vveav a 8vva L VII i VL <br />SWItCB, January 2003 Page t of <br />Secondary Containment Testing Report Form <br />This form is intended fi r rise by contractors performing 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 franr tests (f(applicable), should be provided to the facility owOterloperpla for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FaciiityNante: Date ofTestin :Z -IL _t1' <br />Facility Address:`Lj , E.?D }7 <br />Facility Conlact: Phone: <br />Date Local Agency Was Notified of Testing �--ci <br />Name of Local Agency Inspector (if present during testing): <br />Z. TESTING UU►M KAU l Ux ME` VELMA l lim" <br />Company Name: rt fir+ ' ri1,L,'t'i <br />Technician Conducting Test: j 0:14n, -S,',0n9ftA1109 <br />Credentials: �^CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: Q lg 14eL1'. Eat 1- 7 License Number: y tp <br />Date <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />— <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE. FOR CONDUCTING THIS TESTING <br />Ta lite best of ntV kamvledge, the facls stated ht tills docuntent are uccterate and tit full compliaace wills legal requirements <br />Technician's Signature: Date: <br />