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SWRCB, January 2002 rage I of <br />Secondary Contai ent '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 test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />7 Tu A PTT.YTV TNI, ORMATTON <br />Facility Name: Date of Testing: "T <br />Facility Address:,90 9 S , 6e o �. <br />Facility Contact: MO Phone: q '4 8- Z Lo <br />Date Local Agency Was Notified of Testing : 3 f q <br />-FT 1 A nanry TnenPrtnr 6fnresent during testing): <br />Twvrrnsrr-a•PnT%Tmu A PTnR TNFnRMATTON; <br />-2 --Tnrt:r.4A7DVP.I'i TV..,R'T' RESULTS <br />ComponentComponent <br />If hvdrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TRIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />s .._.n._.. Date: <br />L7 0 <br />Technician's Signature: <br />If hvdrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TRIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />s .._.n._.. Date: <br />L7 0 <br />Technician's Signature: <br />