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SWR.CB, January 2002 <br />Page of <br />Secondary Containment Testing Report Form <br />Phis form is inten ded 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 completedform, 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 />I. FACILITY INFORMATION <br />Facility Name: I Date of Tes ' —1 7-6 <br />Facility Addtess: Q7— 1W.�L or <br />)Facility Contact: 9 e&,,a, 4a I Phone. �� <br />Date Local Ageacy Was Notified of Testing <br />Name of Local Agency Inspector (fpresent durirngtesting: ,� ; y ,Qui W&7- <br />2. TESTING CONTRACTOR INFORMATION <br />Com any Naive, Co <br />P <br />Technician Conducting Test: �,!',.,,, <br />,.- 7^' <br />Credentials: CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: -1- <br />License Number: <br />Manufacturer <br />Manufacturer Training <br />Com ones s) Date n2ining E ires <br />i <br />3 13 An <br />MM <br />MM <br />WArtrAM <br />i <br />i <br />If hydrostatic tesft was perfomad, describe what was done with the wter after completion of tests: <br />CBRTJYICATI <br />To the best of ly knowledge, <br />Technician's Signature: <br />n ' <br />biZ'd Z6Z'ON <br />OF TECHNICIAN TMSPONSIBLE FOR CONDUCTING THIS TESTING <br />st9led in this document are acca ate and m full conWIlance with legal requirements <br />Date:�i' <br />03 1100S WdSi7 : E E002'6 ' Ntif <br />