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L SRCB,January 2002 n \f �f <br /> W <br /> Secondary Containment Testing Report Fof5 13 2003 <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,E-vwJ44en,test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owvner/operator for submittalK lV-bcal regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ;�,{�C Date of Testing: 1 I <br /> Facility Address: joZZ N i-8gA�E cle <br /> Facility Contact: 4 i KAQ Q I Phone:LS09 ��Cj -21iI <br /> Date Local Agency Was Notified of Testing : t 0 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: w -�t' <br /> Technician Condu ting Test: }- o 62 J IC. <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: US= <br /> C50License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass F&H Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> -Av W 1] v <br /> 13 P1 PE KuNs <br /> Zt= F\v NS <br /> z uN <br /> oc <br /> 11 oc- <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> N-VA62L+h 1-;G kj dkC, w n5 pLA- i w+-�O �KSS- Cr-AI LOU cava <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 4.f Date: /o_;f <br />