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PLD� <br />SWRCB, January 2002 Page I of <br />Secondary Containment ITcstingRe#dt4-%HW <br />This form isIntended foruse bycontractors performing periodic t 0fingqf USTS-Aw"ft k4kii"jj#ems. Use the <br />appropriate pages of this form to report results for all components Ifested The comp 4*�*# Vst procedures, and <br />printouts from tests (if applicable), should be provided to the facilifY ownerloperatorfor submittal to the local regulatory agency. <br />Facility Name: S A jj - <br />�30CA&x1*3 <br />t6. Y Date of Testing: pe-, E,,,r <br />Facility Address: 1SIC. ptvF <br />Facility Contact: D"g. t3y4-ot,, Phone: C2,,!2!:,) ey& g - ;3 i 015 <br />Date Local Agency Was Notified of Testing: 03/27/0,1 <br />Name of Local Agency Inspector (if present during testing): pp4%gj-T- <br />2. TESTING <br />Company Name: OA&Lry <br />Technician Conducting Test: S <br />Credentials: &V16SLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: 13 C& i ( D 21, ID 34-. ID -W) LipenseNumber: rl-7416t,,Z <br />aff-M6=1T <br />3- SIMMARY OF TEST RESULTS <br />Date <br />Mill .�� <br />I' i <br />Repairs <br />; 1 .. � ;i 171 1 t 1: 1 ,�� <br />t i <br />r �'i� t <br />on�� <br />�o©o <br />ooa�■ <br />000 <br />0000 <br />�©moo <br />o©moo <br />�o�o <br />o��� <br />c�000 <br />©oc�■a <br />oao� <br />000� <br />�000 <br />�� <br />ons <br />�000��� <br />oaoo <br />0000;: <br />If hydrostatic testmg was performed, describe what was done with the water after cornpletton of tests: <br />W*ff$?- 101J+s "" voa- TMM iT I OF- rkv- L1444P 2- t 'r <br />0 OF TEC1INICL4N RESPONSIBLE FOR CONDUCTING TIHS TESTING <br />To th e b es t q m�N=ne�dg stated in this document are accurate and infull conwilance with legal requirements <br />- I "g Date: 0.iho 7 1-20--r <br />Technician's Signature: oec A <br />