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r <br />SWRCB, January 2002 <br />ae of <br />Secondary Containment Testing Report Fornn °:' 0 5 n�. <br />This form is intended for use by contractors performing periodic testing of UST secondary conta(iitt 10p1 -t sj?slems - ,q�e the <br />appropriate pages of this form to report results for all components tested. The completedform, wrfn te�tprj end <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the loeal rtkbry agency. <br />1. FACELITY INFORMATION <br />Facility Name: �' pV K4 -r -aV VA- a Date of Testing: 1 'L I i Z 1 ij <br />Facility Address: ! aS L"3 �v 5 �-v c k-�-ra , <br />Facility Contact: 14 -cam- Phone: -L� y 16 O 6T.2 - <br />Date Local Agency Was otified of Te g : L Z g o s <br />Name of Local Agency Inspector (af present during testing: <br />2. TESTING CONTRACTOR INFORMATION <br />[License <br />ompany Name: s � t c,,�.� �e ; s�v� <br />Technician Conducting Test a44-1,1 V <br />redentials: ❑ CSLB License Contractor WRCB Licensed Tank Tester <br />Type: -r (� G,g License Number: 470 _1.1 2Z, <br />Manufacturer Trainin <br />Manufacturer <br />Date <br />Component <br />- - - - - - - - - - - - - - - - <br />Component <br />NOR <br />raw - <br />am <br />a000 <br />am= <br />aaroo <br />0000 <br />_ _ <br />oo <br />mm, <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />iP fps Su &a � � _ Cam �' ,�� 7— `terms_ <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts state this document are accurate and in full compliance with legal requirements <br />Technician's Signature: L Date: I 7-11-d a S <br />