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vv av vv a a av+++.+ a near+ tsa. Aaee vv,V,J3LiVV3 AVIV 1 U I <br />SWRC'13, .lanuary 2002 <br />Page I_ of <br />Secondary Containment Testing Report Form <br />This f oft is Intended for use by contractors performing periodic testing of UST seconddry containment systems. Use the <br />nhl,rnl•rklte p agav of this form in report resrdis for all components tested. The completed form, written text procedures, and <br />prinlonls fto/q tests (if applicable), should be provided to the facility otrner/operator for rttbtniltal to the locul regulatory agency, <br />NVA I z 1101 ZV,: • <br />ULU <br />Company Namc: ,�•�P 07 tlil..*rd t,. <br />Technician Conducting Test: <br />Credentials: Y CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />Licensc Type: I License Number: F/05"3 <br />Mgnufacturer.r rainint <br />Manufacturer Com oncnt(s Date Training Expires <br />a etttwtitirsuv nu"'CF_CT RF.c11i.TR <br />� � <br />OMNI <br />mM <br />mmmm MM <br />mom= _ <br />_ om= <br />If hydrostatic testing was performcd, describe what was done with the water after completion of tests: <br />._ -j t ,0.40-- /�Clad y 4/u kkr -6 ea -f -- <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />Tn the hest oj'nty knowledge, tie stated ler this damn tent etre accurate and infill complionee rvltit legal regpirenrents <br />Technician's Signature: Date: <br />Z "/ <br />No <br />