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SWRCB, January 2002 L <br />Page —L of <br />Secondary Containment Testing Report Form <br />This form is intended 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 tested. The completed form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />>h' CILITY INFORMATION <br />Facility Name: ' . f , ,y- ,L Date of Testing: U <br />Facility Address: j 5 ��S n o <br />Facility Contact: o r1 Phone: r _ <br />Date Local Agency Was Notified of Testing: 12—(?21119 , <br />Name of Local Agency Inspector (if present during testing): 9 f <br />2_ TF.CTINf,' d-f1NTu A 1 rnID n TVd-%n1%X A mIF i►T CCD !1 r onnn <br />2 L'I TA4A4 A nV, d-'& ir irv,c T it , nI - m <br />.. iiyLuwLauc ung was periormea, describe what was done with the water after completion of tests: <br />.w t r <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated i this document are accurate and in full compliance with legal re uirements <br />Technician's Signature:' / <br />Date: <br />b <br />0q0 <br />r�000 <br />o <br />000 <br />� <br />noo <br />0 <br />1- <br />oaonv <br />000v <br />normo <br />000 <br />LNrioo <br />0000 <br />MINE <br />_ <br />- <br />,:sono <br />_ <br />o00 <br />noo <br />0000 <br />no�■o <br />nnot� <br />.. iiyLuwLauc ung was periormea, describe what was done with the water after completion of tests: <br />.w t r <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated i this document are accurate and in full compliance with legal re uirements <br />Technician's Signature:' / <br />Date: <br />b <br />0q0 <br />