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,. ......e ..... ... ..... i UL <br />.-o <br />SWIZCB, January 2002 Page t of S <br />Secondary Containment Testing Report For <br />Thisform is inlended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components rested. The completed form, written test procedures, and <br />prin/oatts from tests (!( applicable), should be provided to the facility owner/operator for submittal to the local regulatoty agency. <br />1. FACILITY INFORMATION <br />t'•acility Name: A '.. . I &MPA, u .r 1 Date ofTestig: Z—t t- - V-2 <br />Facility Address:2-1lj <br />Facility Contact: <br />Date Local Agency Was Notified of Testing fr--Ci7;j� <br />Name of Local Agency Inspector (if present during lestlne: <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: w <br />Technician Conducting Test: ;,-� ° <br />Credentials: kCSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />Liconse Type: A ig 14g,67-14, ` <br />Manufacturer <br />License Number: w4 rtU-i 3 <br />Matiyrttcturet' r tnine <br />Cotn onent(s) Date Training Expires <br />T T' s <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To lite best of Illy knowledge, Ire facts stated lot this document are aceterate attd Infill comp/lance with legal requirements <br />Technician's Signature: Date: 7-/U-03 _ <br />