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S WRCB,January 2002 <br /> Secondary Contain�xnt Testing Report Form <br /> This farm is intended for use by contractors performing periodic testing of UST secondmy containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: ► 7g o 5 <br /> Facility Name: 7UAr=HN t F E ea. S55q <br /> Facility Address: R17W • phone: Z 06a - SOS <br /> Facility Contact: ,1e1,I114 ttt2JaN'A <br /> Date Local Agency Was Notified of Testing: III JU4 If OS <br /> Name of Local Agency Inspector(tfpresent during testing):. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comr)anv Name: - <br /> Technician Conducting Test: I mm <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License N <br /> License Type:. umber: � (p <br /> Manufacturer Training <br /> Manufacturer Com onettt s Date Training Ex ires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> gPt� ❑ . ❑ El <br /> R77 ❑ ❑ ❑ ❑ <br /> 1 s Spm L4-- ❑ 11 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> -b-11V—(C ba w `CVg—C�'� ^'T —r Fwutz) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accufate and in fill compliance with legal requirements <br /> Technician's Signa — Date: OJr <br />