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ro <br /> 0 , <br /> S WRCB,January 2002 Page I- of 3 <br /> Secondary Containment Testing Report F <br /> This form is intended for use by contractors performing periodic testing of UST secondary contain t th#.* <br /> appropriate pages of this form to report results for all components tested. The completed form, ' r Xn and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submitter i 'ncy. <br /> I. FACILITY INFORMATION FfEALTH p pA + <br /> Facility Name: \A Y�pp op t I Date of Testing: 111115t16& <br /> Facility Address: 0 3 2_ 1.x.1 A -W`1 Bata �� �_ � , 2.0 <br /> Facility Contact: . aC.&GI 5,dAtA Phone:(-7—o 9-) q( ! , <br /> Date Local Agency Was Notified of Testing: (( 1(a z <br /> Name of Local Agency Inspector(if present during testing): 7-0 4( eq, 14. /-1 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 10 <br /> �,�. i <br /> Technician Conducting Test: !. .e,,,,, u.,L4A_ 'LA, � lr'• <br /> Credentials: ❑CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type: License Number: 60—it-L,,(-) <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 /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> eu ,5 Alcm ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ a ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ D ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ C1 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> I 4--F,(uI 1 SuD( c4l�t6 V'e Co V_& �a. Y2- l? L_o1— tct c ?mss <br /> S e.2,. C-o vv,o,,evt,A-& V e,�?_ � 3 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this-document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: i( ( 5 <br />