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SWRCB, January 2002 <br /> Secondary Contailh aient Vesting ]deport Form,,,v <br /> T7xis form is intended far use by eantraetors performing periodic testing of UST secondary containment systems. Use the <br /> and <br /> appropriate pages of this orm to l ablereportshould <br /> be proovidell components tested The d to he facility owner op r ator fotedform, written test r submittal to the local oregulatory agency. <br /> printouts from tests(if applicable), <br /> X. FACILITY INFORMATION <br /> r <br /> 1 1 Date of Testing: <br /> Facility Narne- 1 L _ C7 NY <br /> Facility AdiF t - e, � �`�' � <br /> Phone: 2 <br /> Facility Contact: Rtir yl <br /> Date Local Agency Was Notified of Testing: lro\J7 b <br /> Name of Local Agency Inspector(ifpresent daring testing}: :F j,\ , <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: <br /> Technician Conducting Test: LU �E' N`� <br /> Pf, ry 0 l`Q 1`C I�N 1 2 <br /> Credentials: 0 CSLB Licensed Contractor KSWR-CB Licensed Tank Tester <br /> License Type: . License Number: C�I u4-j <br /> Manufacturer Training <br /> Manufacturer <br /> Com onerrt s Date Trainins Extaires <br /> j. SUviTvjA moi' OF TEST ESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Componen# fuss Fail Tested Made <br /> p 'Pelted Mede <br /> 1 1 11C ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ a <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ o <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> TO the best of my knowledge,the facts stated in this document are accurate to ful�compliance with legal requirements <br /> Date: <br /> Technician's Signature: /� ' C` r ° , <br />