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E, SWRCEt, January 2002 wit Page of This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: M+ G Date of Tessin g: cX,T 3 v a t Facility Address: / 3 asz U f�b f:a� t C A Facility Contact: Phone: Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: ^.�c Technician Conducting Test: - va- Credentials: N CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License T e: L ypAeAb License Number: Manufacturer Traimn Manufacturer Date Traini .. 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs C Tested Made Component Pass Fail Not Repairs ❑ ❑ ❑ Tested Made ❑ ❑ ❑ ❑ iJrJJt ❑ is ❑ ❑ ❑ ❑ ❑ I ❑ ❑ 11 1 El 01 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ C ❑ ❑ ❑ ❑ ❑ ❑ ❑ E. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ J ❑ ❑ ❑ ❑ ❑ ❑ ❑ L ❑ ❑ ❑ ❑ ❑ ❑ L ❑ ❑ ❑ I ❑ ❑ If hydrostatic testing was performed, describe what was done wrth rhe amntar .,q— ,qAr CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: OT_. 3c, 02 //'7