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DE" 1 2008 <br />SWRCB, January 2002 1 aC C r, , ,, i -r <br />Page of 1 <br />x N 1� 0 �iy��tr�;�tt_1 r � - <br />Secondary Containment esfii g 'eport 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 forvn, written test procedures, and <br />printouts from tests (j'applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: EUk.,j t--k(-4v4— Date of Testing: E �, us <br />Facility Address: \3O\ C -e4- ke vv m" L -et -Q.... de -c t , q 5 ,2 Q <br />Facility Contact: 2v� 7'� Gf Phone: (z01 `3 Y4- `3 23 <br />Date Local Agency Was Notified of Testing: 1 l 5 O8 <br />Name of Local Agency Inspector (if present during testing): <br />2_ TESTINGCnNTR A CTnR 1NTi nRM a T1nN <br />Company Name: R � o, i u .e Q `� S <br />o 7 <br />Technician Conducting Test: l� e,+.. a,-, , U <br />LAI ,- (_ �. <br />Credentials: ❑ CSLB Licensed Contractor <br />WRCB Licensed Tank Tester <br />License Type: l i,c- -e' S - <br />License Number: (� -; ! .() `(CyG2 - 44 °- <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Tested <br />Made <br />Tested <br />3. SUMMARY OF TEST RF.SITI.TS <br />Component Pass <br />Fail <br />Not <br />Repairs <br />Component <br />Pass <br />Fail <br />Not <br />Repairs <br />Tested <br />Made <br />Tested <br />Made <br />�nwctltt r_ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />1 ❑ <br />❑ <br />- � CERTIFICATION OF TECHNICIAN <br />To the best of my knowledge, the facts stated in this 0 <br />Technician's Signature• // ---/-,-1L-----1 <br />RESPONSIBLE <br />---a--- <br />RESPONSIBLE FOR CONDUCTING THIS TESTING <br />vcu ent are accurate and in full compliance with legal requirements <br />,...,..�:., Date: f �e <br />GNU <br />01m <br />ME <br />m <br />Ilm <br />KU©©O <br />DM <br />____Ell <br />®oo� <br />o��■©� <br />_ <br />- � CERTIFICATION OF TECHNICIAN <br />To the best of my knowledge, the facts stated in this 0 <br />Technician's Signature• // ---/-,-1L-----1 <br />RESPONSIBLE <br />---a--- <br />RESPONSIBLE FOR CONDUCTING THIS TESTING <br />vcu ent are accurate and in full compliance with legal requirements <br />,...,..�:., Date: f �e <br />GNU <br />