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Feb. 2 2015 12:48PM No, 5 15 0 P, 3 <br />4. <br />aWRM, January 2002 Page I of <br />Secondary Containment Testing Report Form <br />This form is Intended for use by coneractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of thisform to report results for all components tested: The completedform, written testprocedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to thelocal regulatory agency, <br />1_ FArYYT'T VYr*Mn'0MA'TTYAV <br />Facility Name: 2- v 1 t ]late of Testing: 2--19 - t S <br />Facility Address: 835S C. •4 I,-, TACKJ-o✓u ,jt. <br />Faoility Contact: Phone: <br />Date Local Agency Was Notified of Testing : <br />Name of Local Agency Inspector ({f present during testing): <br />r <br />7. °1"F.C'T`Tl�f,: ("nli1T'R A rTnR TNFn72MA'I`Tnl\T <br />Company Name-, <br />(�trayue Perry, IncWE <br />Technician Conducting <br />Test: ICC# a' "CoA eAC <br />lGk � va: ®/ a 3 � <br />Credentials: Cl CSL)3 Licensed Contractor ❑ SW)RC$ Licensed Tank Tester <br />License Type: <br />A, P, c10, C21 /.D40 Haz License Number: 300345 <br />Manufacturer <br />Manufacturer Trai:nxng <br />Component(s) Date Training Expires <br />Furnished Upon Request <br />C ' 1►llu' � : � : 'i 1 v <br />.�, <br />1'1����Mm:Sr <br />ijagn <br />� <br />00000 <br />oroo�i <br />oo�oo, <br />mom <br />ova© <br />oaa <br />0000mom <br />oo=0 <br />00 <br />®, <br />0000 <br />00 <br />o <br />000 <br />0 <br />0 <br />0 <br />, <br />�■� <br />MMMM <br />0 <br />, <br />0 <br />MM= <br />MM <br />00 <br />oa <br />: <br />o <br />If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the faet8 stated in this document are accurate and iWfull Compliance with legal requirements <br />Technician's Signature: t Date: <br />Received Time Feb,23. 2015 12:57PM No.8185 <br />I <br />