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SWRCB,January 2002 • Page Of <br /> Secondary Containment Testing Report Formic c `Y/ , L <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. U.se the <br /> appropriate pages of this form to report results for all componene--itsted. The completed form, written test proceduQ aptaQ 2008 <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulat?,7 agency.}- <br /> 1. FACILITY INFORMATION <br /> Facility Name: c�oo A, � Li es,uLo r Date of Testing: 3 o 0 <br /> Facility Address: t a 15' We E4-'L-t)CN -cu' S44L1 c,4 , 1 : 1 <br /> Facility Contact: -Pdt,,U �_ V-0 p tJ=-- Phone: 2 p 33 3 (O 3 00 <br /> Date Local Agency Was Notified of Testing: () 8 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:?-- <br /> Technician <br /> ame:?--Technician Conducting Test e„ r�ti,,,; 1 V, C_ <br /> Credentials: ❑CSLB Licensed Contractor "W$WRCB Licensed Tank Tester <br /> License Type:,Svj`(LLT3 `Tckin�-_=-e License Number: <br /> _. <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 /> Tested Made Tested Made <br /> ►i P1 u 1 etv Tew El El 11 11 El <br /> El 11 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> e.c. �� _ � z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> et= ❑ ❑ ❑ ❑ <br /> s ;,,. u �. ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> L-- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Utz_ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> LAi itfg ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> —T--s t t l S,±t 12 1 d e r� f'�4o-L1e e%&I -1c l�It`'f' J U 1,9 S"n, C;-fs <br /> i- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this.4cument are accurate and in full compliance with legal requirements <br /> e , <br /> Technician's Signature: '� w°'a. Date:' <br /> IS-1) �� <br />