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SWRCB,January 2002 F�'ECGEII`AHQ) 1-ofPage <br /> Secondary Containment Testing Report ForrlY 4 2008 <br /> This farm is intended for use In'contractors performing periodic testing of UST secondary conminment sisr nvs dAhe <br /> appropriate pages of this form to report results for all components tested. The completed form,'-►written test procaiFbres, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ugencv. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Iq r(tj v, SDate of Testing: <br /> Facility Address: I 11)p OtA ,LAtet* e r g �! 5-3Facility Contact: l<u L '5 ka rvv\ � Phone: C5(o) (e8-23T <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: ; ; D �� e u v <br /> Credentials: ❑CSLB License,,, Contractor WRCB Licensed Tank Tester <br /> License Type:-Tetmje,7-e .1-eY License Number: �Q-tIZU �G� SZy�gaz-�eT <br /> Manufacturer Trainin¢ <br /> Manufacturer Com"onent s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail <br /> Tested Made <br /> a can lc_ 1 ❑ ❑ ❑ t'iC 7 L )L ❑ ❑ [j <br /> ta«to 'et rTc.w lc. zr fel ❑ ❑ ❑ ❑ ❑ ❑ <br /> o <br /> Fe C' .2 1 ❑ ❑ ❑ U 41-,Ry uµj #1:— <br /> Ft ( rlw/ uw > ta- ❑ ❑ ❑ <br /> ,h L4"�' #Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1L ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C4 D e-- 2- f5 ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> 3 £ ❑ n ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> N d rt 12 aZ '?-d &4A w I, d ✓ r�u g t .., itu*t •� t� <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> Tip the hest of my knowledge,the facts stated In tht document are accurate and In full compliance with legal requirements <br /> Technician's Signature Date: (J((� <br />