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S SWRCB, January 2002 <br />Page of <br />Secondary Containment Testing'Report Form <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />t - A!'TT.TTV MFORMATION <br />i• 1'<A vi.uaa a <br />Facility Name: e1,7rr � 19 K h Date of Testing: <br />Facility Address;, —tom; k e�'ro r r D11Y <br />Facility Contact: p �a I 17 �t ( e t �C Phone: <br />Date Local.Agency Was Notified of Testing: <br />Name of Local Agency Inspector (tf present during testing): <br />rrr mm�srn'nn�rrr-u A PWID TNTiOPMATION; <br />ComponentComponent <br />� ■5����� <br />000 <br />OMS <br />0��0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />El <br />p') W i- 0 1"'! <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledb e, the facts stated in this document are accuFate and in fill compliance with legal requirements <br />Technician's Signature: G�`"�- Date: <br />U <br />