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SWRCB, dahua* 2002 <br />Page of <br />Secondary Containment Testing Report Form <br />This f t -m k intended for use by contractors performing periodic tasting of UST secondary containment systems. U.se the <br />appropriate pages of this form to report results for all components tested. The completed forma, written test procedures, and <br />printouts from tests (af applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1, FACILITY INFORMATION <br />Facility Name: Date of Testixag: «r 1 �' C <br />Faeility Address: ` /,fir,.• L eae <br />Facility Contact: y <br />Date Local Agency Was Notified of Tegtiiag <br />Name of Local Agency Inspector (rfpresent during testing): <br />2, TESTING CONTRAC' <br />Company Name: d o w z <br />Techniciatx Conducting Test: <br />Credetatials: CSL$ Licensed Cobtraetbr <br />License Type: %Tlvw_ <br />SWRCB Licensed Tank Tester <br />License Number: <br />7- <br />Tom' <br />If hydrogtAtic tmtitng was performad, describe what was done with the water after completion ®Rests: <br />C1E~ RTIFICATI OF' TECIMICIAN RESPONSIBLE FOR CONDUCTING THIS VESTING <br />To the best of kttowied; s d in this document are accurate and fit full compliance with leg&d requirements <br />Technician's Signature: Date: <br />612•d 082.0N <br />03 1100S WdZZ:TT 6002'6 •Ntif <br />