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i� ECIEVED <br />SEP L 5 2006 <br />SWRCB, January 2002 ENN ENT44of—�- <br />Secondary Containment Testing Report Fore IT/SERVICES <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 />1. FACILITY INFORMATION E' I <br />Facility Name: �„ h -t,7 -� Qv -t ::�dket I Date of Testing: <br />Facility Address: <br />Facility Contact: c) Q r Phone: p <br />Date Local Agency Was Notified of Testing: O 23 e—) <br />Name of Local Agency Inspector (i(present during testing): <br />rP1 Q9rY? 0_ rnNTD A nrrnn YWTr+nn1l,r 1 Tlr 1XT <br />Company Name: ,,,� <br />� � g 3 rti <br />Technician Conducting Test: Q yr <br />` yy�1)4 (�6C. ,r r <br />Credentials: D CSLB Licensed <br />ontractor CB Licensed Tank Tester <br />License Type: % /G � � <br />Manufacturer <br />Y " License Number: �i - // 2-0 <br />-'Manufacturer Training' man <br />Component(s) Date Training Expires <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />PtU10k f 2 <br />S c®n�a <br />❑ ❑ ❑ <br />❑ ❑ ❑ <br />0 <br />❑ <br />❑ <br />❑ <br />3. <br />SUMMARY OF TEST RESULTS <br />Component <br />Pass Fail Not Repairs Component <br />Tested Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />PtU10k f 2 <br />S c®n�a <br />❑ ❑ ❑ <br />❑ ❑ ❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />C t' tz- <br />❑ E) 11 <br />El <br />El <br />D <br />❑ <br />t aPva Z <br />it QC. #-3 <br />❑ ❑ D <br />a ❑ ❑ <br />❑ ❑ ❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ ❑ ❑ ❑ <br />❑ <br />❑ ❑ ❑ ❑ <br />❑ <br />❑ <br />El El <br />❑❑ <br />❑ ❑ ❑ <br />D <br />❑❑ <br />0 <br />❑ <br />❑ ❑ ❑ D <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests:, <br />1 ❑ I❑ <br />❑ <br />❑ <br />CERTIFICATION OF TECHNICIAN <br />To the best of my knowledge, the facts stated in this d <br />Technician's Sianatud.-- <br />VSIBLE FOR CONDUCTING THIS TESTING <br />are accurate and in full compliance with legal requirements <br />",^.r Date: �% <br />