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MM <br /> SWRCB I,January 2002 NOV 2 7 ZOOZ Page of <br /> Secondary Containment Test* <br /> This form is intended for use by contractors performing periodic testing of WjNbj&W96'Qinment 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(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1, FACILITY INFORMATION <br /> Facility Name: I Date of Testing: j <br /> ' AL dldc J X 2, <br /> Facility Address: Pale; ., )'z <br /> Facility Contact: Phone:-�459 ?— j 17 ' <br /> Date Local Agency Was Notified of Testing: /I? &-/ `e- <br /> Name <br /> e-Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> V_ —Ta � <br /> Technician Conducting <br /> Credentials: CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: 'V)I-Ap qnkA PA' ) <br /> License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Ti4ted Made Tested ,Made <br /> 41 Z,/X" 11 0 <br /> El Ej ire 0 <br /> n7tr 0 <br /> 0 El 11 11 El H'I El <br /> tie <br /> 7-VIf-I IFy'v-Z 1,3 El 11 7 <br /> 0 0 k"T 0 <br /> 0 zo El f 0 11 0 <br /> .-WAf Ptr-r,3 Oe�E, D El El 0 0 0 <br /> �rtI14 e- <br /> -1----—0 j <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 9Q11U0 C01-11-Y-)CA10� F1_I Lw0 d i t A Y-,A <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the/Barts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />