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SWRCB, January 2002 �a a e L of g <br /> N 1k ( el — <br /> Secondary Containment Testing Repwor�r 1po� <br /> This form is intended for use by contractors performing periodic testing of UST secondarybS4stems. Use the <br /> appropriate pages of this form to report results for all components tested. 7ffe completed lbr., M ,�� cedures, and <br /> printouts from tests ftf applicable), should be provided to thefacility awner/operator for submittal to t<�scf6egulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ot N M 5 u e.L I Date of Testing: L O I 2-cl O <br /> Facility Address: l 4 1. 5o u4-lk 4 t r dv4-(1+) I � <br /> Facility Contact: V c,, phone: $5 -O(O I <br /> Date Local Agency Was Notified of Testing : L 0 3 D'7 <br /> Name of Local Agency Inspector(+fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:iz 4 D Co w.i7 I i cern e e -T;s 4-t,,j <br /> Technician Conducting Test:-h e ci un i vt f. Du t ut N Tr <br /> Credentials: ❑CSLB License Contractor CB.Licensed Tank Tester <br /> License Type: k�, lc :es4--eV License Number: p-1 1 Zv <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made I I I Tested I Made <br /> nNula✓aun vj4Y ❑ C1 El <br /> i <br /> -;2i -r S'Ce � ❑ ❑ ❑ <br /> fe cc,N ❑ 1 ❑ ❑ Q 1 ❑ 1 ❑ ❑ <br /> Se ewidJ 1,2e.it y ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> *3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5eev"A'X'a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> G f ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 17,-,2 n ❑ ❑ ❑ . . 0 ❑ ❑ ❑ <br /> r n 1 Sust 2 IX 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> #1 1- 12- ❑ ❑ ❑ ❑ ❑' ❑ ❑ <br /> �5 t(, 4,1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing w performed,describe what was done with the water after completion of tests: <br /> TPsk u !dSi.t� it ¢N'fA ' reu N,u� I� Cawnl 'a.�ceTS�Li. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in 1 document are accurate and to full compliance with legal requirements <br /> Technician's Signature7l t«4 :v-' Date: Z <br />