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Secondary Contaimment T'esting'Report For <br />This form is intendedfor use by contra sperformingperiodic testing of UST secon 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 (rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: MAIr r v Date of Testing: e,17a <br />Facility Address:Lj o 'iA <br />Facility Contact: Phon . g Z 6 <br />Date Local Agency Was Notified of Testing: Lp j 3® a (p <br />Name of Local Agency Inspector fif present during testing): <br />2. <br />TESTING' CONTRACTOR INFORMATION: <br />Com anv Name: Am,01a <br />Technician Conducting Test: <br />-- 5 <br />Its <br />Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type:. <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires . <br />' <br />3. SUA Y OF TEST RESULTS <br />Component <br />Pass FailNot Repairs Component <br />Tested Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />ST EF, LZ <br />❑. <br />❑ <br />❑ <br />❑ <br />t 'rte t �-- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 101 <br />❑ 1 <br />❑ <br />❑ 10 <br />1 <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was One with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the acts st tot current are accurate and in full compliance with legal requi ements <br />Technician's Signa;;7 _ _ Date: <br />