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SWRCB, January 00.-, Page <br />_of_ <br />Secondary Containment Testing Report Form <br />This form is infendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of Phis form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />I- FACIT.TTVMFORMATTON - "I - <br />Facility Name: - r — 0 1 Date of Testing: 317�777 <br />-eW - <br />Facility Address: ze Z�,* <br />Facility Contact: /t/%Aj Phone: ;? 0 3 q1 <br />Date Local Agency Was Notified of Testing: <br />12-,5 &/0 r <br />Name of Local Agency Inspector (if present during testing): /\,Ou -'e-, <br />2. TESTING CONTRACTOR INFORMATION 0 <br />3. SUMMARY OF TEST RESULTS <br />Component F Component <br />MRI M. <br />0 <br />=�,, <br />0000; <br />0000 <br />0000 <br />oo�■o <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />o�too <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />__0000 _ <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 Date: <br />