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� n <br /> SWRCB,January 2002 Q U Page 1- of <br /> Secondary Containment Testing e 6 <br /> This form is intended for use by contractors performing periodic testing of UST se ms. Use the <br /> appropriate pages of this form to report results for all components tested The co t procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator i a to t e local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 1-/1 z h', a V4- Date of Testing: 12 O S <br /> Facility Address: 3"'� O-� cti yrv�r�e)y� cA<--�-av, Czc, 13 5-2-0 ,7 <br /> Facility Contact: ''V ut,S 5 Phone:(-Z,421) 1.51 -9,16,0 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Z 1) i&v�,(-e. ;e <br /> Technician Conducting Test:"1j P,,,,�tG w ,vr1 '-, D Ln u (e <br /> Credentials: ❑CSLB Licensed Contractor KSWRCB Licensed Tank Tester <br /> License Type: -ra4 t V_ -r-e�4-e,.K License Number: 4t C) -l 12,6 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> �% 4aV, t� 3 0 0 0 ❑ 0 ❑ ❑ <br /> Se cv"4d_ Y l PC,-4z— 0 0 0 ❑ ❑ 1 ❑ 0 <br /> f.t i i �'3 ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> 5� e 2, ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> L DZ VLA �- ❑ 0 0 0 ❑ ❑ ❑ <br /> i vim. � ❑ 0 ❑ ❑ ❑ 0 ❑ <br /> GI: C €Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tAV L-4*-3 t 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowdedge,t/ce facts stated do this cuaaaent are accurate and in full compliance with legal requirements <br /> Technician's Signature: f x.� Date: '2 <br />