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January 20M <br /> ?age Of <br /> Second2ry Containment Testing Report Form — SpillBur-k-ets <br /> 7?Tis fnrrn is Intendedf®r use b.v:;ontrac.ors performing period e&-sang of,'ST secondary containment system . ase the <br /> appropriate pages of.his farm to report rysuttsJhr all components tester The completed form, ;written test proc-adures ;mad <br /> pr,ntouis,�om tests(if appilcable), should be provided to the facility ownerioperator,i;r:;unmiital:o the!rocs!,7gaalatoP7v agenc. <br /> 1. FACILITY INFORMAnON <br /> Facslisy;dame: a4///�ceins err I Date of i';stiS1T. Z <br /> Facility Address: c. <br /> Facility coma= Phone: <br /> Date Lneat Agency Was Notified.of Testing: <br /> Nam of Local Agency Inspector(if present during testing): <br /> I TESTING CONTRACTOR O% TION <br /> Company Name: T Inc. <br /> Technician Conducting Test r? <br /> CA X CSL,B Licensed Canmcmr C S CB Licensed.Tank Tester <br /> License Type: D-40 <br /> 1 <br /> tuner C nt{s) DIM T - <br /> s <br /> 3, a NOAARY OF'PEST RESULTS <br /> Not Comp j FUSS Fad I Tamed 13Z as a Component 7355 I Fail TL ted f <br /> f <br /> U j Li r <br /> IL <br /> 1 <br /> Lj �? Q ❑ C <br /> 171 ❑ r IAC r ' <br /> u j n n i ) <br /> If liyarostmc testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICAnON OF TECBIC3AIN IRESPONSIBL<E FOR CONDUCTING TMS TEST-ING <br /> To the nest tar'm'kirawledge. the`mess.wed iss this tltx=ment are ace Brute rnd n foil c Urnpliar:ce h e;al reurairemesaas <br /> z. <br /> T=anican.'s signature: mate: ,� <br />