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g <br /> SWRCB,lanuary1002 a .1 of <br /> DEC 0 <br /> Secondary Containment Testing ReLrR!�Q.hi?d® <br /> This form is intended for use by contractors performing periodic testing of UST seconds #14 Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, dures, and <br /> printouts from tests(if applicable), should be provided to the fact ity owner/operator for submittal to the oc 1 regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 5 Date of Testin : Z,( <br /> Facility Address: v Pwi-V 6o-vn '54-Yr4at... (10- ca eck , `� 3 <br /> Facility Contact: Phone: Z_o 2_3 -4f Y <br /> Date Local Agency Was Notified of Testing: '711-7/02 <br /> Name of Local Agency Inspector(rf present during testing): <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: 'R .'- i 4wt-0- -T-5 <br /> Technician Conducting Test j�V, #.00^^ V tAt IV', <br /> Credentials: 0 CSLB License Contractor K§WRCB Licensed Tank Tester <br /> License Type:`ic un 1C. S License Number: Qh-i f'ie[J ti#.SL 6902_-L! rt'� <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fall Not Repairs <br /> Tested Made Tested Made <br /> 6n KW 2- ❑ ❑ ❑ e,£/O ❑ ❑ ❑ <br /> Ir ❑ ❑ ❑ 6Vt- ❑ ❑ ❑ <br /> cea J&,, Pelle hl_� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> c ee.'6 , a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e �a ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> W 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> W ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> .1 e: z.- 0 ❑ ❑ 0 0 ❑ ❑ <br /> I_Ude-*3f ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> (U rpt'`,- ❑ ❑ 0 0 0 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> QST fi l ci Cl I x.'. ✓*c 'GeL &� 1)'awre f1✓¢ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In tlels dor t are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: rl lat <br />