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SWRCIt, January 2002 i6 Wage l of Z <br />Secondary Containment Testing Report Form <br />7YJis.1: -1-111 is intande'd fur use by contractors perfor»ting periodic le,Yting of UST secanda,y containment syste►»s. Use the <br />crl,p, nlu iate pug.�x of th/s. fornt to report resales fol- all camprrnents tested. The completed form, written test procedures, and <br />priarmns from tests (If applicable), should be provided to the factlity utvner/operator for sub►nitial to the local reguiceaory agency. <br />1. FACILITY INFORMATION <br />Facilily Name:Q � vti+ Dat- of Testing: <br />Facility Address: -Z_ut-)VC- p'*m6 P�.. G <br />Facility Contact: taeMVedt.. A one: <br />pate Laval Agency Was Notified f Testing :_ p G– V <br />Natne of Local Agency Inspector (if present during teslingJ: <br />2. TESTING (A <br />company Name: Kcrv% <br />Technician Conducting Test: -t~ Sii�►w.. <br />Credentials: X CSI.B Licensed Contractor. <br />License Type' A A -e. <br />Manufacturer <br />)1LL) %^ S <br />mr�e <br />SWRCB Licensed Tank Tester <br />License Number: NS W91 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To Ilse best of eny knowledge, tl acts Oted lit this doeOsncitt Ore Occurate aced lir frill colrrpliairce wide legal reyuireertetets <br />Techniclan's Signature: Date. r��U3 <br />� <br />N\ <br />