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05 FAX <br />SWRCB, January 2002 <br />?'his form is intended for use by <br />appropriate pager of this form t <br />printouts from tests (if applicab, <br />Facility Name: r i3 <br />Facility Address; <br />Facility Contact: zr s ; r_Q r, <br />Date Local Agency Was Notio <br />Name of Local Agencv Insueci <br />-► SJEH lih002 <br />Page �_ of { <br />iiry Containment Testing Report Form <br />lac#ors performing periodic testing of UST secondary containment systems. Use the <br />W results for all components tested The completed form, written test procedures, and <br />,ould be provided to the facility owner/operdtor for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Date of Testis . 7 . <br />' �' i 'ter �� E LA _ ct �. , e . C_ E),A ;. 1�c. , 'S ;L. <br />Phone: 'jA - 61 — 2-7`70 <br />esting ; to 5 <br />present daring testing), <br />Z. STING CONTRACTOR INFORMATION <br />Compare Name: 1Z i .� ; a -r " -`�� <br />Technician Conducting Test: a v.a %AA, w \ ,,,tt n L^—* V . <br />Credentials: ❑ CSLB Li ed Contractor WRCB Licensed Tank Tester <br />License Type'` ­� – P : • r. License Nurnrber. <br />. �____r --. SII �$dii�g&�llClrLTrninitea <br />Date <br />C>ERTIFICATI01 OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thi fach staled In tfils it4' me►it are accurate and In jbil compliance with legal requirements <br />Date: <br />1 /J -- — <br />r_ 22 <br />J'i 3. <br />SUMMARY OF TEST RESULTS <br />Component <br />Pa <br />;, <br />Paas <br />Fail <br />Not <br />Tested <br />Rspah+ <br />Made Component <br />Paas Fall <br />Not <br />,t."� <br />Repairs <br />t!lrrt !tr rut[/_. <br />r�i <br />Cl <br />❑ <br />❑ .iF tom. <br />11 <br />C1 <br />Made <br />~ <br />El <br />13 <br />x(41.'11 <br />11C . ! �% C* �+ t FP <br />k <br />d <br />❑ <br />❑ <br />i?9 'tI. <br />:! <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />Cl <br />Cl <br />S r `'� :', '!ir r Ja. ��• 1, <br />�� <br />❑ <br />❑ <br />lt'rr r Jou,, <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�.���, ►. 1 .r!, <br />II <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />11 <br />0 <br />D <br />11 <br />11 <br />Ili <br />A. <br />if hydrostatic testing was perfota/d, <br />describe <br />what was done with the water atter completion of tests: <br />.r...��„ ♦.rn• i •! r �/ <br />1 i �.e. <br />"(` r. <br />.3 <br />% 'vim •/: Jr �"� 1 �/i►1�IF ���r' <br />. <br />:�rr.�,. `,� ^I <br />...��... <br />,ft <br />ii <br />ill <br />✓ ` <br />—• ---� .w... <br />.� <br />- <br />/ <br />C>ERTIFICATI01 OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thi fach staled In tfils it4' me►it are accurate and In jbil compliance with legal requirements <br />Date: <br />1 /J -- — <br />r_ 22 <br />