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19255517888 Main Fax GETTLER RYAN INC 0" ' 47 p in. 12-05-2006 2/3 <br /> r <br /> SWRCB,January 2002 Page l of Z <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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: /4Qc—p p Zl Date of Testing: 12. 1-0 ( <br /> Facility Address: s 2 r Z ✓ Cc Q. N ; +4�e 4./" <br /> Facility Contact: `�d 4ec!,cru Phone: Lac. <br /> Date Local Agency Was Notified of Testing: ZZ Q <br /> Name of Local Agency Inspector(if present durink tes ng): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 6-7c. 4 <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:C57, B, C61/D40, HAZ A, HIC C1 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> = 7 -/2-C <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Fry <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: _ Date: 12-- <br /> I`d <br />