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1 0 RmSVED Y:� <br />SWRCB, January 2002 ®As o2foge J- of <br />Secondary Containment Testing Report FAMMENT Thisform is intended for use by contractors performingperiodic testing of USTsecondary coma�f e <br />appropriate pages of this form to report results for all components tested. The completed form, xgrt en 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 />Y 1 W46 10 ze-TIMIT.Vt M, <br />Facility Name: --o C4,,�A- e C ,v✓ VJqS Date of Testing:( <br />Facility Address: --c ctvAwt� r' ,S o k- , ` S - 12_. <br />Facility Contact: ��Y S S3 uS c \ t <br />Phone: 2U .S th - 40 b <br />Date Local Agency Was Notified of Testing-. /p <br />Name of Local Agency Inspector (ifpresent during testing): <br />Company Name: 17 ca,,,, i t. - 7,777- ► <br />Technician Conducting Test: Lk ,,I ; ta. Wt 't a -t <br />r , o Ctt &-t jr , <br />Credentials: p CSLB Licensed Contractor <br />9SWRCB Licensed Tank Tester <br />License Type:,:j tc- Fs -.e r- <br />License Number: S-2- q6 6tj2- <br />Manufacturer <br />Manufacturer Trainin <br />Com onent s Date Training Expires <br />Ind <br />MMM <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />f ews-e. /6VA eD 6,01) 114wre >5' ®'t - <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this c • ent are ac urate and in full compliance with legal requirements <br />Technician's Signature y-� °� - Date:_ <br />MM <br />Ind <br />MMM <br />nu <br />aoo <br />oo■c.� <br />MIMMo <br />_aoo <br />'��r�i�ti�l.��� <br />►' <br />�■ <br />�� <br />000 <br />0M <br />on= <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />f ews-e. /6VA eD 6,01) 114wre >5' ®'t - <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this c • ent are ac urate and in full compliance with legal requirements <br />Technician's Signature y-� °� - Date:_ <br />