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Apr 20 04 08: 43a L H Facilities Management (21339-7672 p. 5 <br /> SWRCB,3anu wy 2002 page ® OQ <br /> Secondary Containment Testino Report .Form <br /> This furr1f is intended far use by contractors performing periodic toving of UST seeondat;y crarttuinmC>rt systc ns Use the <br /> appropriate pages of this form to repurt results for all components tested, The completed form, written tesr proccdurc.7,and <br /> printuutsfrom tests(if applicohic),should be provided to the facility owner/uperatur for submittal io the local reg*uluiory afrency. <br /> 1. FACILITY IN'FORIVLATION <br /> Facility Name: / e / Date of Testing: --Q <br /> Facility Address� <br /> Facility Contact: fq•nL1� _ / Phone. <br /> Date Local Agency Was Notifiedof Testing: - j6ri "Q Al <br /> Name of Local Agency Inspector(tf present during testing <br /> 2. TIESTING'CONTIZACTOR ORXATION <br /> t'.nmnanv Name; 12 <br /> Technician Conducting Test: ,[ l ® 'M IQ <br /> Credentials', 0 CSLB Licensed Connctor (4SWTtC6 Licensed Tank Tester <br /> License Type:. License Number: <br /> Mnnc®facturor Trseinin� <br /> Manufacturer Com ®nent Date Trainin Ex fires . <br /> 3. S Y OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Paas Fait Component Pasta p"�t Teatcd Made <br /> p Tested Ma�tc <br /> r ` p D ° ❑ a <br /> ® ❑ Cl o ❑ <br /> c L m '1rrV ❑ ❑ ❑ � <br /> r❑� o a ❑ <br /> a © 11o ❑ ❑ <br /> ❑ Cl ❑ _o__ <br /> o ❑ o ❑ <br /> ❑ ❑ a <br /> o ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CEIt'I'[FICATIO OF cfacts stated tn�le>dIANuCumPnt ore accu'ate and CONDUCTING <br /> ll con pilTHIS <br /> wTESTING <br /> El g,�Gtluiremcn1v <br /> To lite best of my knowledb e, <br /> Technician's Signature: -_ Dstc; <br /> oh r ran e.n n7 add <br />