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e c <br />M t x <br />SWRCB, January 2002 Page I- of <br />i <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 tWform 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 />I. FACILITY INFORMATION ' t <br />FacilityNaine:'SS.., C�r�;iv� aw Date of Testing: 14 10 <br />Facility Address: L 0 4- (4-.:::, v% Arve.. 5J6 G <br />Facility Contact: �j ( C, r...� Phone 'moo t{ to T- 3 to S <br />Date Local. Agency Was Notifleeof Testing: -?72-7 O <br />Name of Local AQencv Insnector (if present during, testing) <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE. FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In this meet are accurate and in full compliance with legal req irements <br />Technician's Signature - Date: l n <br />EmComponent <br />0. <br />• <br />If hydrostatic testing was perfonned, describe what was done with the water after completion of tes.ts: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE. FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In this meet are accurate and in full compliance with legal req irements <br />Technician's Signature - Date: l n <br />