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i IC <br />S WRCB, January 2002 Page i, 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 (if applicable), should be provided to the faci* owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 54cY-Jov-, A-IAA� C -,,y (A)6,S tA Date of Testing: L L I ' j 0 <br />Facility Address: 3 43 q ee g-+ S ) A S a 1-L , <br />Facility Contact: GI. ✓ c 5 1 u c �{ t; c` Phone: 6-o; D (� <br />Date Local Agency Was Notified of Testin : 112- U <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />SUMMARY3. <br />Component <br />Pass Fail <br />Tested <br />Not <br />Repairs <br />Made <br />Component <br />Pass Fail <br />Not <br />Tested <br />Repairs <br />Made <br />ve.ta wa l a <br />j"u i I- <br />❑ <br />❑ <br />❑ <br />to n e- &&-3 <br />❑ <br />❑ <br />❑ <br />u <br />t 2£3 <br />❑ <br />❑ <br />❑ <br />tA0G-a-5 <br />❑ <br />❑ <br />❑ <br />5 ��ori <br />e�'1 <br />❑ <br />❑ <br />o <br />P L L 2 r5•+zr Sww. -� s <br />❑ <br />a <br />❑ <br />S e c o^aa. <br />Ute -42- <br />kj ❑ <br />❑ <br />❑ <br />FiLA R rS,, Su.+µ 41-- 2- <br />❑ <br />0 <br />❑ <br />Seerm�ex <br />r3 <br />❑ <br />❑ <br />❑ <br />ili�� 3 <br />❑ <br />❑ <br />❑ <br />STP Q= ar <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />STC} -t>I ' p <br />*z <br />Nr ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I b,wj <br />5kVA <br />❑ <br />❑ <br />❑ <br />❑ <br />�D�`� z ❑ ❑ ❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />❑ <br />❑ <br />❑ <br />❑ <br />T; S'An <br />�.X"e. G6 <br />6- 14 . —O Ux,<, S <br />J <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowled ,�-th acts stated in thisnt are accur to and in full compliance with legal requirements <br />Technician's Signatu4 - Date:1/17467 <br />