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Do 7 <br /> S W RCB,January 2002 <br /> Secondary Containment Testing Repad Far&& 'L�= <br /> This form is intended for use by contractors performing periodic testing of UST sec�� grrt : <br /> appropriate pages of this form to report results for all components tested. The contplc an� i �rY�printouts fi om tests (if'upplicuhle), should be provided to ihe'fact}'m>>r7er.'operator or su mit a7 ro F,*,Frocedures, <br /> alf{ yrjr&VctNLTH <br /> 1. EACILITY INFORMATION PERr0f T/'-'-R V1 C E S <br /> Facility Name: T7_0 1 Yt Um/ bej 5C_GeeU1 l�lS-�i'rZ� Date of Testing: <br /> Facility Address: 3.L C-,L- i j1,zd Avi <br /> Facility Contact:13u 4-GA S:- t n LZ--` l Phone.-(7-D17 933- 729q <br /> Date Local Agency Was Notified of Testing : yRS' Q� <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: iJ� _ori ,-;/i -T�-f4 i -q <br /> Technician Conducting Test: ;..i.tt t i +'' t" Mvm, eet,,�'t jV, <br /> Credentials: ❑CSLB Licensed Contractor RCB Licensed Tank Tester <br /> License Type. la License Number: 5;•q -t(2,0/ <br /> j� jDZ-e!`j- <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Com onent Pass Fail Not Repairs Not Repairs <br /> p Tested Made <br /> Component Pass Fai! Tested Made <br /> 1 N t t r a,- �(lC `' ] <br /> _ -L ❑ ❑ ❑ �, � ` 1� i n ! �.,F ��- ❑ ❑ ❑ <br /> 2— 12 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> �r Grp Inti ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> If hydrroostat testing was performed, describe what was done with the water after completion of tests: <br /> v? �rrr�r'� �i� <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 /> i <br /> Technician's Signature: Date: /2-11 Z,d 6d <br />