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SWRCB, January 2002 Page of <br /> � � <br /> For o <br /> Secondary Containment Testing Repo npECFTED <br /> This farm is intended for arse by contractors performing periodic testing of UST secondary contairameart systems. Use the <br /> appropriate pages of'this form to report results for all components tested.. The completed form, written teson,Iutfs1pJU1 <br /> printouts f'om tests( 'applicable), .should he provided to the facility owner/operator for submittal to the local r•egulZitortyagency. <br /> 1. FACILITY INFORMATION ENVIR ANT HEAL.TI] <br /> NOW <br /> Facility Name: �t �A+ 7_kT A.- <br /> Date of Testing: <br /> Facility Address:,%D C7 vt1 LkL <br /> Facility Contact: ID JA c(ate►t at C1 r o Phon(: <br /> Date Local Agency Was Notified of Testing: 2- <br /> Name <br /> Name of Local Agency inspector(ifpresent during testing): nr7 9 <br /> _ 2. TESTING CONTRACTOR INFORMATION <br /> Company Name ] It", <br /> Technician Conducting Test: P-)e,�^ CCVIA; 1A.Cay, r' <br /> Credentials: 0 CSLB Licensed ontractor WRCB Licensed Tank"fester <br /> License Type,'{rtind 1Gr 1't$ V License Number: Q -I C ZQ � 5 �4Z—ufi <br /> Manufacturer Trainin <br /> Manufacturer Com anent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS Not Rep:slrs <br /> Pass !~ail Not Repairs Component Pass Fail Tested. Made <br /> Component Tested Made <br /> ❑ ❑ ❑ ❑ <br /> h►n ul Gt t �-` L] El ❑ ❑ ❑ ❑ <br /> iA an it�c l a✓ Tia }e-1_1 f ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5�t�vt fav �-� ❑ ❑ ❑ ❑ ❑ �� ❑ <br /> �-r t.c t �-` ❑ ❑ ❑ <br /> ear t ❑ Cl ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1-1 C] 0 Ll L] ❑ <br /> 2 ❑ 11 ❑ ❑ ❑ C� <br /> - ❑ 1� ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done wit he water after completion of tests: <br /> .� U S k 7 l Vit r� ✓ <br /> s TESTING <br /> CERTIFICATION Off'TECHNICIAN RE;SPON re accurate to CONDUCTING wnte with legal requirements <br /> To the Best of my knowledge,d facts stated in this d cutnent are <br /> Date:f-5 __-_--�--------_-_ <br /> Technician's signature: r - <br /> -- <br />