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N <br /> S WRCB,January 2002 Page I 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(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: tE yw iY)ez? C U Date of Testing: f $f Q jj <br /> Facility Address: jq0 C /! rn v G f. LGw(o <br /> Facility Contact: G 1 G I _r) o rsa 4 S Phone: 3 — 7 <br /> Date Local Agency Was Notified of Testing: j —1 t v& <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: tD ow P j;exte-t eS 1+4 <br /> Technician Conducting Test: 3ee..j.1 M>H E DU K ee&— Jr' <br /> Credentials: ❑CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type:—FeAA1c Tef,+et/ License Number: <br /> Manufacturer Trainin <br /> Manufacturer Component(s) nnxfres <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Re airs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ?,,,v tc%r,t t e l ❑ o ❑ <br /> wda, r z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t�z -oe ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 7 t:e, , tt ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatiLj <br /> c testin was performed,describe what was done with the water after completion of tests: <br /> "tKr / 'i,�..r,'A'�r .7 a d ./ _ ,OIH i /ewe e - /f^� <br /> t <br /> CERTIFICATION OF TECHNICL4,N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in thisdet<?r nt are accurate and in full compliance with legal requirements <br /> Technician's Signatur : ` (//,� Date: (l 4 <br />