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FE -))ECJ <br />Lq VE DD <br />SWRCB, January 2002 JAN 0 5 2090 Page _`_ 0f <br />Secondary Containment TI� Pirm <br />This f orm is intended for use by contractors pertbrming periodic testin"0j <br />sec ainment systems. L'se 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: -T-L j c�) <br />t� P. l Date of Testing: 1 l <br />Facility Address: <br />ct 4- �Z� U <br />Facility Contact: <br />cA t <br />Date Local Agency Was <br />otified of Testing : ( Z (� <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: fZ� �) v, t av�,- Q T t., - .k <br />Technician Conducting Test: .p_�,, V,-, <br />u V\_ e c, V -L <br />Credentials: ❑ CSLB Licensed ontractor <br />IkSWRCB Licensed Tank Tester <br />License Type: '( �� -,t- <br />License Number: r Q _11z16 T - <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Repairs <br />Made <br />N�H�Gc�?tG.: <br />❑1 <br />❑ <br />❑ U 1).. <br />r i r <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />N�H�Gc�?tG.: <br />❑1 <br />❑ <br />❑ U 1).. <br />❑ <br />❑ <br />❑ <br />b <br />❑ <br />11 <br />El=f <br />`f t' <br />❑ <br />❑ <br />❑ <br />Pl,6t: L,l t lttf G�Ut IC _ <br />I <br />❑ <br />I� <br />❑ <br />J <br />❑ <br />❑ <br />❑ <br />CtiYt� Gia , Zt <br />❑ <br />❑ <br />❑ <br />Q <br />Q <br />Q <br />Q <br />C e e,,,v,IAA Q 2k. I/ <br />❑ <br />❑ <br />i7 <br />❑ <br />C7 <br />❑ <br />it <br />c i r I -e A3 <br />❑ <br />❑ <br />❑ <br />❑ <br />IJ <br />❑ <br />❑ <br />- rlfr -f� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />!J <br />1 <br />U <br />J <br />J <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />u <br />�c S �i-4 Srrnahr j a.. -J Yr, fis r.�a✓cP e/ tr Lr/ r ®� tea.., e"rius T"vr .'orifi <br />CERTIFICATION OF TECfINICIAN RESPONSIBLE FOR CONDUCTING rms rES"rlN(-,, <br />To the hest of my knowledge, the facts stated in Ntls do in nt are accurate and in frill con(pliartce )vith legal requirements <br />. <br />I'��rhnlclan s Si -nature, � O,ate: <br />