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19255517888 Main Fax 13ETTLER RYAN INC 0:50 a.m. 05-16-2007 2/3 <br /> / S'WRCB,January 2002 Page / of 2 <br /> Secondary Containment Testing Report Form <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 testprocedures,'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: Cfi'Et//ZDA/ e Z 0 C//6 7Date of Testing: O¢-/z-O <br /> Facility Address: <br /> Facility Contact: Phone: Z O CJ ?1 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: (S�al-74/er az -,c- <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor. SWRCB Licensed Tank Tester <br /> License Type:C57, B, C61/D40, HAZ A HIC C1 License Number: 220793 <br /> Manufacturer TraininE <br /> Manufacturer Com ones s Date Training Expires <br /> Pkil 4 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fall Not Repairs Component Pass Fall Not Repairs <br /> Tested Made Tested Made <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 60ale.1' 41-- ✓t eTf/11 a (,7 !:& -1 ! tzc, n.: Sig o <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and an full compliance with legal requirements <br /> Technician's Signature: /V11/11-1(- Date:__0 4 -I Z 0 ' <br />