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SWRCB,January 2002 Page / of 2 <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 resultsfor all components tented. The completedform, written testprocedures, 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: L A Plaa J6'- 063/ Date of Testing.- <br /> Facility <br /> es i Facility Address: W 5. IK A t N C <br /> Facility Contact: -Mottl1v SC OE_ Phone: 2.69- <br /> Date Local Agency Was Notified of Testing : 4/8 lows P,e x <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: -r A!5—WI S <br /> Technician Conducting Test. CRA16 <br /> Credentials: SL CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A A-,56 License Number. rf0gS' <br /> Mannfasturer Tr&Wug <br /> Manufacturer ones s Date Training E fres <br /> b U <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Frq ELL <br /> v fro lz <br /> LYES-T- V A olt <br /> ? S F/cc 4 <br /> If hydrostatic testing was performed,describe what was done with the water after co letion of test: <br /> �.t. LsaQ1��� ��u11L s s- - <br /> CERTIFICATION OF TECBMCIAN 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:— � <br />