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SWRCB, January 2002 Page of <br />Secondary Containment '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 />printoutsfrom tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY IlYFORMATION <br />Facility Name: Lt, �,a,: - n n /,/,0( Date of Testing: <br />Facility Address:c <br />Facility Contact: Phone: -116 <br />Date Local Agency Was o ified of Testing: `�— — C9 / �} f.} ' it Y` c, <br />Name of Local Agency Inspector (ifpresent during testing): VL <br />2. TESTINO'CONTRACTOR RUORMATION <br />Com an Name: f Lur <br />Technician Conducting Test: r e <br />Credentials: 0 CSLB Licensed Contractor FTWRCB Licensed Tank Tester <br />License Type:. License Number: C ' -) =//4 <br />Manufacturer Training <br />Manufacturer Com onent s Date training Expires . <br />,.,..r. T,tT 9,n TLVQm DV Q1r TT mgr <br />Component <br />Component <br />MW -�� <br />oovo <br />'����■�momomm <br />momma <br />norvo <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 fadl compliance with legal requirements <br />a <br />Technician's Signature: Date: <br />