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SWRCB, January 2002 Pagek_of �- <br />Secondary Conta hent Testinb'Report Form <br />4 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 <br />Facility Name: Lj f E� 4�� Date of Testing: ?,- �C� __ <br />Facility Address: +100 e, . V. C <br />Facility Contact: (Z-2 tc. & <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector ('(present c <br />2. TESTING'CONTRACTOR IlVFORAIATION: <br />_T�&f <br />g testing): <br />Phone: 2vq,. 5%_S • K-7-94-1 <br />Technician Conducting Test: -\ )" 1- L p - l K tr <br />Credentials: ❑ CSLB Licensed Contractor gSWRCB Licensed Tank Tester <br />License Type:. License Number: <br />Manufacturer Training <br />Manufacturer <br />Components) Date <br />.� mrnm w-%'nc'TTf rVO <br />-- ....... _.M® <br />Component <br />-... <br />i <br />ANN <br />0000 <br />No <br />-N__ <br />If hydrostatic testing was performed, describe what was done with the water atter compienon or tens: <br />_ e <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, ilie facts stated in this document are accurate and in fill compliance with legal requirements <br />Technician's <br />Date: <br />