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. Secondary Contasnent Testing Report Form <br />This form is intendedfor use by contractorsperformingperiodic testing of UST secondajy containment systems. Use the <br />appropriate pages of this farm to report results for all components tested. The completed form, 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 />1. FACILITY INFORMATION <br />Facility Name:IQ I Date of Testing: y C& Z,� <br />Facility Address: {� -j 5XI N)d t vx C-1 95 <br />Facility Contact: (3\(>„Vld o <br />Phone: (20 1 $1 Z <br />Date Local Agency Was Notified of Testing: Q <br />Name of Local Agency Inspector (tfpresent during testing): j UI <br />r YI► ►YY:. • IU : 4 : Y • <br />company Name:K4 <br />- - - --- - - <br />Technician Conducting Test: <br />Q. N I {Nl M <br />Credentials: ❑ CSLB License8 <br />Contractor WRCB Licensed Tank Tester <br />License Type:. <br />License Number: r /) q <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires . <br />3.CITrv"1 v1ARV QF TEST RESULTS <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 and in full compliance with legal requirements <br />Technician's Signature: / ! (.ltiL''✓j� Date:j <br />