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Mar. 19. 2014 10:10AM No. 3963 F. 3 <br />Page I of 14 <br />Secondary Containment Testing Report Form <br />This form it Intended for we by contractors performing periodic testing of UST secondary containment systeins. Use the <br />appropriate pages of this form to report results for all components tested The completed form, written tegprocedures, and <br />printouts from tests (af applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency, <br />1. FACTLITV DM*RMATTn1q <br />Facility Name- (bf) H "0 1 Jg bateofTest <br />Facility Address: 33,55 C, &b)m6r bul lskckt <br />Facility Contact: <br />Phone: <br />9 J"" 6r <br />Local Agency Was Notified of Testing: L /a - I Ll <br />[NDate <br />ame EEel Agency 1wpector (if present during testing), <br />fIT"WIRMIT"TrIFT-W MR, <br />Company Name: Wayne IPer ,Incorporated <br />Technician Conducting Test:f <br />" 4 � il` & ct�_– ICC– # <br />Ci �ti a I s: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type, A, HAZ, C21, CIO, B , C61, D40 I License Number: 300345 <br />1VlanufaetuGrer Training <br />Manufacturer Component(s) Date Training Expires <br />jq j2a,3jZ_j 144 Furnished on re nest <br />If hydrostatic testing was pea -formed, describe what was done with the water aft completion of tests: <br />MAR 19 2014 <br />LTH <br />CIERTVICATION F TECHNICIAN nsPoxsmu FOR CONDI[ MNG THIS TESYMPTM ENT <br />To the ben of my knowledge, the ads stated M this document are accurate and to full eoVftance with legal requirements <br />./l/' <br />Technician's Signahnv: Date:— <br />