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SWRCB, January 2002 <br />,Secondary iReport <br />Page of <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this 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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: s ¢ �� f- �v 0'" Date of "t'estmg: ",i - b �-- V& <br />Facility Address: p (p 1 GQ W i t,+ <br />Facility Contact: , ;. Phone: ( D z - <br />Date Local Agency Was Noti d of Testing: <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING' CONTRACTOR INFORMATION <br />Company Name: - r ' `' _" 7„ <br />Technician Conducting Test: , t G <br />Credentials: ❑ CSLB Licensed `Contractor CB Licensed Tank Tester <br />License Type:. License Number: <br />Manufacturer <br />1 <br />Manufacturer Training <br />Date <br />Component <br />Component <br />MOMS <br />momma <br />or.�oo <br />MOM <br />MM <br />11MON <br />0000 <br />MOM—, <br />000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 />f S`? Date: <br />ature: <br />Technician's Srgn � � ., <br />