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. 1 1: FC7, (-�' [E- M <br />SWRCB, January 2002 p8of <br />F <br />jul'i 1 5 2 9 <br />Secondary Containment Testing Report Form <br />I N'T E AI <br />This form is intended for use by contractors performing periodic testing of UST secondary contain ENVIRONNME AT <br />appropriate Pages of this form to report results for all components tested The completed form, writ est AM and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />I. FACILITY INFORMATION <br />F TDate 'ofTestin <br />Facility Name: t-11 R- L 1�t- a--e� V?A-e(A <br />Facility Address: qtj_------ ------- X- <br />0 C <br />_ale A -(AV <br />Facility Contact: <br />lc 110 v -i A -e Phone: -2 1 17, <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ii(present during testing): <br />--2. TESTING C <br />it " =01- A , <br />Company Name: e <br />L <br />Technician Conducting Test: -6 1 V\ - A, I vt <br />I <br />'F� <br />Credentials: 0 CSLB Licensed ontractor <br />License T y p �e:T-&,, �% �1,/- <br />�—I< e V - <br />Manufacturer <br />UV, t;\ e 'x vt <br />WRCB Licensed Tank <br />License Number: T - <br />Manufacturer Training <br />cre';!Javl <br />tf <br />If hydrostatic testin <br />—Ies+ I- � �A , <,. <br />*-P1MT01-jVFw,-WscnDe wt was one t e water after completion of tests: <br />6, � 2,4 w3 a-2-- 6�(-1- 1 <br />Date Traini <br />00 <br />1,3_1 <br />MS <br />IN©� <br />low= <br />Vlm= <br />am= <br />E1511110 <br />WIN= <br />IBM <br />am <br />1 <br />m <br />©m=ter <br />am®ter <br />*-P1MT01-jVFw,-WscnDe wt was one t e water after completion of tests: <br />6, � 2,4 w3 a-2-- 6�(-1- 1 <br />Date Traini <br />00 <br />1,3_1 <br />MS <br />IN©� <br />Vlm= <br />raimm <br />E1511110 <br />IBM <br />am <br />1 <br />m <br />©m=ter <br />am®ter <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated /it thumm` eare accurate and In full compliance with legal requirements <br />jf ' -do <br />Technician's Signatur Date: <br />