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FROM : B. Z. SERF I CESTAT I ON MAI NONCE FAX NO. :916 371 2548 abec. 28 2005 04 : 28PM P5 <br />SWRCB, January 2002 Page .-- of � <br />Secondary Containment Testing Report Form <br />7"his form Is intended for use by contractors performing periodic testing of UST secondary containment .sy sterns, Use the <br />appropriate pages of thiyform to report results for all components tested. The completedform, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Y. FACILITY iNFORMA'.17ON <br />FnciI4 Name: 1 �, Dgto of Testing: M� `6 . q <br />Facility Address: <br />Facility Contact: ;✓� 5L^ -- _ 1'lionc <br />Date Local Agency Was Notified of'Testing: <br />Name of Local Ageney insp&ztor (ifpresant during resting): <br />2, TESTING CONTRACTOR INFORMATION <br />Com an Name: &r - <br />P299 <br />Technician Conducting Test: <br />' 1(16-1 ., 5 <br />Credentials; &CSLB Licensed Contractor <br />O SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number; �y 3,715 <br />Manufacturer TrAlid <br />Component s) Date rra. ng I: Mires <br />W <br />❑ <br />3. SUMMARY OF TEST RE, SULTS <br />Component <br />P299 <br />Fail <br />Not <br />Vested <br />Repair® <br />Mack <br />Component <br />PABA <br />Fall Not <br />Tested <br />Repairs <br />Made <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />�❑ <br />AL <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />r ti <br />L <br />W.t?- <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />JL <br />❑ <br />❑ <br />❑ <br />❑ <br />D( ❑ <br />❑ <br />9 <br />❑ <br />❑ <br />❑ <br />© <br />D ❑ <br />0 <br />❑ <br />1 ❑ <br />❑ <br />0 <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Q <br />❑ <br />u ❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after 4yrnpletion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSMLE FOR CONDUCTING THIS TES'T'ING <br />To the best of lily kny rig the facts stated lit this document are accurate and br fkrll compliance 01h legal requirements <br />Techniclarr's S gnature: Date: 9- U <br />