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S`dRCB, January 2002 <br />Pageof _ <br />Secondary Containment Testing Report Ford -,-J 0",-# :RMIE <br />This form is intended for use by contractors performing periodic testing of UST secondary con sA.1,7,� .54 <br />appropriate pages of this form to report results for all components tested The completed form, i e rocedures, 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 F7 Date of Testis : ( C <br />Facility Address: <br />Facility Contact: 17,41LI( Phone: 240"! (_ . — () <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: t <br />Technician Conducting Test: e -se- n`( <br />Credentials: CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br />License Type:L L` `�' License Number: <br />Manufacturer Traininr....,, <br />s <br />Manufacturer Component(s) Date Training Expires <br />i <br />3. SUMMARY OF TEST RESULTS <br />ComponentMM <br />Wai.MMWL"IM <br />goo© <br />o©oo <br />opo© <br />oao <br />neo© <br />o�aoQ <br />as©© <br />aioc�� <br />aanoo <br />anotf <br />©oma■© <br />raoo� <br />OM <br />E <br />000� <br />nnoo <br />ono <br />: <br />oan�o <br />�©ray©• <br />oaoo <br />f __ <br />air�or <br />� <br />aoor� <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 facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 1 5'16 -3 <br />