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SWRCB., January 2002 Page of <br />Secondary Containment Testing Report Form <br />' ''his form is intt�nded for use by contractors performing periodic testing of UST Secondary eontaimficni systems. Use the <br />appropriate pages of this farm to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should beprovided to the facility owner/operator for submittal to the local regulatory agency. <br />a. FACILITY INFORMATION <br />Facility Name:k-r IDate ofesting: - <br />Facility Address: -S % \4,-Z �! <br />Facility Contact: IPhone: S - <br />Date Local Agency Was Notified -of Testing : to -1 t- p <br />14ame of Local Agency Inspector (fpresent during testing):- j 1 <br />2. TES'TIN'G CONTRACTOR INFORMATION <br />Company Name; co <br />Technician Conducting Test. <br />Credentials: CSLB Licensed Contractor S $WRCB Liomsed Tank Tester <br />License Tyke: 9SAIAM I License Number: QQ-1IS5 <br />Manu fa cturcr_yra i n ing <br />Manufacturer Com onent s Date TrainingExpires <br />— _i r -ICAc- <br />If hydtbstatic testing was pedformed, descn'be what was dome with the water after completion or rests: . <br />R <br />CERTMC,A.T'ION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of may ►rnowledgd, the facts stated in this documew are .accurate and in fun c®mpliance with legal requirements <br />Technician's Signatam: Date <br />6iZ'd 08Z'0N r` 00 1100S WdSti:TT 6002'6 'Ndf <br />