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SWRCB, January 2002 <br />rage vi <br />' Secondary Contain nt T'eStinor'Report Form 6 <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:, Date of Testing: fo - 2— <br />Facility Address: K Ae ►-a �a t �" <br />Facility Contact: �' Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (tfpresent during testing): <br />Component��®i <br />.. ,®� <br />®® <br />momma <br />000 <br />mo <br />O�DO <br />MMS <br />���� <br />■ <br />000'. <br />MMMT <br />oac�o <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 accuS ate and in full compliance with legal requirements <br />Technician's S <br />Date. — <br />