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t <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary 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(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: At2P' M 041 LAA,I21 IG <br /> of Testing. N1ls, 31,'-2,<D1 �- <br /> Facility Address: 76?-7S 50 -PAXVE= <br /> Facility Contact: i L Ft-V,64� Phone: <br /> Date Local Agency Was Notified of Testing: M4'V q,2,-Inr-2- <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION ETII/IRONMEM•AL HEAl <br /> Company Name: <br /> Technician Conducting Test: lv <br /> Credentials: -KCSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: je, License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Go tz s -s't'S t^s.y -Lo <br /> SIE5 V�lj key --C L) �l zo t3 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 1111 11sem' sxlt--�P ,� 11 El <br /> �s�0 L-M - oerl "as 1111 El � ` _ 11 11M�1 c14tZ le'I stA.v E ElEl El00C-- �� � ❑ 1 ElEl <br /> APOOLINOL 91 �4 El El 0 &0C, <br /> s�cro�txatz� 7 syFwo ❑ El El �' ❑ ❑ ❑ <br /> ❑ ❑ ❑ i,L 4o lA;r' ❑ ❑ ❑ <br /> c� z-t71Ae 87 s 'F A ❑ ❑ ❑ <br /> S-01- a jk El ❑ 11 El 11 11 ❑ ❑ ❑ <br /> ,467 <br /> STP St17 Sym ❑ ❑❑ ❑ ❑ ❑ ❑coP�,v- <br /> ❑ ❑ ❑ <br /> �CJ4�t P ''/i�tA� ' ❑ ❑ ❑ ter%R►rJCr ►'�t�3�lro�z l►J� ❑ ❑ ❑ ❑ <br /> P P e`7 StV <br /> AE ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 arts stated in this document are accurate and in full compliance with legal requirements <br /> /v <br /> Technician's Signature= Date: MAY -S 1 t 2G <br />