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J VV W D, Jd[ivary LVUG +use vi <br /> -#Secondary Containgent TeSting'Report Form <br /> This form is intended for use by contractors performing periodic testing of UST 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: /6® � <br /> Facility Address: 47-75- t rte+ ca r r® �-a 0 <br /> Facility Contact: k,0, �,.4` m• ,I� , r I Phone: *t - -3 31-°- -7"-? <br /> Date Local Agency Was N tified of Testing : to -It- ®'j 1000 <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION <br /> Com an Name: 41 V4, <br /> Technician Conducting Test: / iM <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s), Date Training Expires . <br /> 3. SL74MARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> [Tested Made Tested Made <br /> pit ( �J ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TJ-1-7T We-r f� >f �3� -5"1 <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: ]° %' `r Date: <br />