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: S4# 11 12 11:00a Elite IV Contactors 12094616342 p.2 <br />tit i 1v .. W 1ILL`1 <br />S.W'RCB, January 2042 a i Pager of <br />econdary ontainment Te ing epo A Form <br />This form is intended for use by contractors performing periodic testing of UST seeondiir r:ontainment systems. Use the <br />appropriate pages of thisform to report results for all components tested The completea i)rm, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner./operator for: aSmittal to the local regulatoty agency. <br />I. FACILITY INFORMATION _ <br />Facility Name: j Satt of Testing•. <br />Facility Address: �,__ � G �-` � <br />Facitity Contact: '-"�'`-- <br />3 Phone: <br />Date Local Agency Was Notified of Testing: ' <br />Naive of Local Agency Inspector (if present during testing): ; a, <br />2. TE TING CONTRACTOR INFORMATION <br />Company Name- I V. •! ,tr`' <br />Technician Conducting Test: <br />Credentials: CSLB Licensed Contractor SWRCB Licensed Tank <br />.License Type: License Nu11101 1 <br />mber: <br />as <br />Manufacturer Trainin- <br />Manufacturer Com onent(s) <br />`i_ CTT•MM®I2V n� Tx•c-r n>i. �Trr me <br />If hydrostatic testing was performed, describe what was done with the water after completi n of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTI _'(3 THIS TESTING <br />To the best of my knowledge tlrefaets sttued entA Beu t are accurate and an full cam dance with legal requirements <br />Technician's Signature: <br />Date: <br />VAM <br />i <br />If hydrostatic testing was performed, describe what was done with the water after completi n of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTI _'(3 THIS TESTING <br />To the best of my knowledge tlrefaets sttued entA Beu t are accurate and an full cam dance with legal requirements <br />Technician's Signature: <br />Date: <br />