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14far.03.2012 02:37 PM RA&Environmental SWIRCB, January 2002 559 294J445 PAGE. 2/ 10 Page ....—_ of Secondary Containment Testing Report Farm Chis form is intended for use by contractors performing periodic testing of UST secondary containment systems, Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, I l; A CII .I'TV INIi (lI2M A TMN Facility Name r: U I Date of Testing: Facility Address- b +,rftgy Facility ConPhone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: IRZ 61itvhamlkl --_�.._.�..w...�.�..,........... Technician Conducting Test: p � Credentials: RSLB Licensed Contractor ❑ SWkCB Licensed Tank Tester License Type: License Number: 0M Manufacturer ManufactmEer. Traitor Component(s) Date Training Expires MMM Mon ;, MI 1 ®0 I Q17JMMARV nF TVC%T RF..r,IJI.TS If hydrostatic testing waq performed, describe what was done with the water alter completion of tests: CERTIFCCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING: To the best of my knowledge, the farts stated In this document are accurate and in full compliance with legal requirements 'T'echnician's Signature: V L= _ _ Date: s 4 y "' ®® MMM Mon ;, MI 1 ®0 © • 3 i is •' (�1i© w' Ai. �� . Y,1i�1 :.• � �1. r .F �` • .,.: ill,©® .. �i,.. MA1 i. ffj®M.. If hydrostatic testing waq performed, describe what was done with the water alter completion of tests: CERTIFCCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING: To the best of my knowledge, the farts stated In this document are accurate and in full compliance with legal requirements 'T'echnician's Signature: V L= _ _ Date: