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SWRCB, January 2002 Page of_ <br />Secondary Containment Vesting Deport Form <br />This form is intended for use by contractors performing periodic testing of UST secondm y 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 />V A r~rr rrry rvWnR M A TION <br />Juix JL i <br />Facility Name: Date of Testing: �� 6 <br />Facility Address: oo C. ®5` <br />Facility Contact: SAZAIV <br />Phone <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />TESTING CONTRACTOR INFORMATION <br />Com anv Name: "� 4? <br />Technician Conducting Test: <br />Credentials: ❑ CSLB Licen ed Contractor ASWRCB Licensed Tank Tester <br />License Type:. Li nse Number: <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Ex fres . <br />T ,T <br />Component <br />ommm <br />i n <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 f cts stated in this document are accurate and in full compliance with legal quiremertts <br />Date: <br />Technician's Signature: <br />l <br />