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! 1 IJ UG UU. J111n I,Awn arall VVltlj 111 UV 11 V14 1 U.l <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for we by contractors performing periodic testing of UST secondary co►ttainment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested The completed form, written test procedures.and <br /> printouts from tests(f applicable),should be provided to the facility owner/operatorfor submtaal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ak Ea, b+-n Date of Testing: Ip Gi-L. <br /> Facility Address: Z.cq 3!jj Gvt <br /> Facility Contact: (a/� •• �//rc hone: <br /> Date Local Agency Was Notified Testing: <br /> Name of Local Agency Inspector(i present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> C Name: <br /> Technician Conducting Test: ,..,, <br /> Credentials: CS Con SWRCB Licensed Tank Tester <br /> License Type: „�� License Number: VV l ol- <br /> liLManafaetuMr Training <br /> ManufacturerCom s Date Training Ex pires <br /> 3. SUNEKARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Mad® Tested Made <br /> l�4 wt+4✓ <br /> 7-7 'v vs Y- <br /> R' 5, �. <br /> Ri <br /> moi - t6 X <br /> r X <br /> If hydrostatic testuig was ed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fa ed In Ikk documew are accurate and In full compliance with legal requkements <br /> Technician's Signature dz====== Date: A—Ir may__ <br />