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SWRCB,January.2002 A 2 8 2009 Page L Of 2 .- <br /> Secon pp RR"VE <br /> LT Testing Report Form <br /> This form is Intended for use by contra�`t Pk rmin eriodic testis o USTp gp g f 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 /> FacilityName: UVL4-dA_ Gr-aT jDateofTesting: Q <br /> Facility Address: i-{40 (/J est- (' Q eV, W4L,A $ Gl <br /> Facility Contact: 6r o! (el- Phone 114 –12 () <br /> Date Local Agency Was Noti fied of Testing: O O L Ute. F(q <br /> Name of Local Agency Inspector(fpresent during testing): _ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: `� Co,-,Q t i a S l V, <br /> Technician Conducting Test Q,,, iv'l UAA e! <br /> Credentials: ❑CSLB Licensed tontractor WRCB Licensed Tank Tester <br /> License Type.� \L License Number: Q – 112_v .�C.71"5Z. 02,_..L,1 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> U � t ❑ fV ❑ ❑ ❑ 0 0 ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ 0 0 <br /> ❑ ❑ 1 0 ❑ 0 ❑ ❑ 0 <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ 0 ❑ <br /> 0 0 1 0 0 0 ❑ 0 0 <br /> 0 0 ❑ ❑ 0 0 ❑ 0 <br /> 0 ❑ ❑ ❑ - ❑ ❑ ❑ 0 <br /> ❑ 0 ❑ 0 ❑ 0 ❑ 0 <br /> 0 '0 ❑ 0 ❑ ❑ ❑ 0 <br /> ❑ 0 ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 1 u- tit; e -e.C—OW446c, <br /> E? •c t� d <br /> i <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS'fESTING <br /> To the best of my knowledge, the facts stated In this document are accurate and In full compliance with legal requirements <br /> Fechnician's Signature:-_ .�, --,--_ -`-- Date: <br />