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SWRCB,January 2002 AUG _ Mge '—of-?-- <br /> Secondary <br /> oof7Secondary Containment Testing Report ROMWENT HEALTH <br /> This form is intended for use by contractors performingperiodic testing of UST secondary contatrinithtmW&P.v eYhe <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 /> $ ao 0 1. FACILITY INFORMATION <br /> Facility Name: va 3 2— I Date of Testing: �p <br /> Facility Address: O Al, rA.6t rte_ COL 5' <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: —l y-O S <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t v N <br /> Technician Conducting Test: 1 kr< <br /> Credentials: KCSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: h tk k _ e License Number: &q-?J164— <br /> Manufacturer <br /> Q3J164— <br /> Manufacturer Training <br /> Manuf er Com orients Date raisin <br /> Coil Expires <br /> L rc. r (0 86 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ . ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> -CrL - ©t•. St <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: /� �j7j ���� Date: 7— OS <br />