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Page f of 0 <br />SEP 2 5 2008 Secondary Containment Testing Report Form <br />e by contractors performing periodic testing of UST secondary containment systems. Use the <br />// s form to report results for all components tested. The completed form, written test procedures, and <br />pri 6 es applicable), should be provided tithe facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name:5 �vG,c { c, vt G� c� xa_,t� ` %yDate of Testing: `1 / /0 ( 0 <br />Facility Address: Z ZZ Sou �e�-� c�t� `j%v�2Q-� S U���-� U� (:! 2 0 <br />Facility Contact: 2 D N S OL V+, C, �x e,-- Phone: (Z.oC? rj <br />Date Local Agency Was Notified of Testing: 2g OF)* <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name:'?- <br />Technician <br />ame:'Technician Conducting Test: <br />Credentials: ❑ CSLB Licensed Contractor WRCB Licensed Tank Tester <br />License Type.'T-eA/A ar_T:eS - y License Number: <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />iec.--4-fu,.l l# -I`or (� V.W "i kl le,? U <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this ment are accurate and in full compliance with legal requirements <br />Technician's Signatur : a• Date: l Los <br />Component <br />d0 <br />■ <br />KNOMM <br />momMIA: <br />r�000' <br />aoo <br />aoo. <br />: <br />000 <br />0000 <br />ooaa <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />iec.--4-fu,.l l# -I`or (� V.W "i kl le,? U <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this ment are accurate and in full compliance with legal requirements <br />Technician's Signatur : a• Date: l Los <br />