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SEP -7-2006 08:17A FR0M:D&SDRAgLjNE SVC 2098268699 IQ:46e3433 P.2 <br />SWRCB, January 2002 Page — of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic resting of" UST secondary containmert r sYsrems. Use the <br />appropriate pages of thus form to report results for all cumponents tested. The complered form, written test procedures, and <br />prfniouufrom tests (if applicable), should be provided to thefactlity ownerloperatorfor submittal to the local regulatory agency, <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing, <br />Facility Address: GCa. <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agciicv Inspector (if present during resting): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ptS 26-a.A�, <br />- Lev - <br />Technician Conducting Test: <br />Credentials: C LB Licensed Contracto <br />License Type: <br />Type: = d (,/� <br />Mn9facturer <br />SWRCB Licensed Tank Tester <br />License Number: <br />iVlanufucturer—Training I <br />Component(s) Date Training Expires <br />�r�� <br />� ilii <br />I SUAMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was dune with the water after completion of tests: <br />CERTIFICATION OF TECHNICLLN RE' SPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and k'jull compliance with legal requirements <br />Technician's Sic <br />1-� <br />,mature: Date: <br />Wool <br />�r�� <br />� ilii <br />MONWIMM' <br />If hydrostatic testing was performed, describe what was dune with the water after completion of tests: <br />CERTIFICATION OF TECHNICLLN RE' SPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and k'jull compliance with legal requirements <br />Technician's Sic <br />1-� <br />,mature: Date: <br />