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4 <br /> SVIRCB,January 2002 Page of <br /> ContainmentSecondary <br /> This form is intended for use by contractors performing periodic testing of USTsecondary 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 from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: i of Testing: ! W1 t <br /> Facility Address: i.IT <br /> Facility Contact: i Phone: ZQ S-19 -4/0 /Y <br /> Date Local Agency Was Nota ed of Test1 t <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION A?V <br /> AZU <br /> Company Name: <br /> Technician Conducting Test: 6- 4 <br /> Credentials: 24SLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number: EQ37 <br /> anactrer T king <br /> Manufacturer Com nent s Date Training Expires <br /> t d 4/20 //3 <br /> r T p <br /> 64 t l /3 <br /> . SUMMARY OF TEST RESULTS <br /> Component Pass Fait Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ba3Q",&:9La ❑ ❑ ❑ ❑ ❑ ❑ <br /> 7 tX 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> c ❑ ❑ ❑ C, ❑ ❑ ❑ <br /> 1 19 ❑ ❑ ❑ Ill ❑ ❑ ❑ <br /> 7 SUW6, R ❑ ❑ ❑ Vrt ,%vKF gZ ❑ ❑ ❑ <br /> 1 9 ❑ ❑ ❑ -"i ❑ ❑ ❑ <br /> Oil ❑ ❑ ❑ *71V s ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> STP n ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UC)C-- t ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION F TECHNICIAN RESPONSIBLECONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this docunsent are accurate and in full compliance with legal requiremena <br /> Technician's Signatur • Date: / •-�.1'� zz <br /> - <br />