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11—IJ—UG U I .44fivi fAVivi hr All UVI110IAUUI IVIV i UL <br /> AWL <br /> SWRCB,January 2002 Papa of <br /> Secondary Containment Testing Report Form <br /> This form is Imended for'use by contractors performing Periodic testing cif UST secondary containment.systems. Use the <br /> appropriate pages of this form to report results for all components tested The eompletedform, written Pest procedures, and <br /> printouts from tests(lf applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INVIORBUTION <br /> Facility Dame: 1P Cu Date of Tasting:l p ++ <br /> Facility Address: ?- & A t-lof <br /> ® Facility Contact; V-104A.04d 14 ile I'Phone: ..� <br /> Date Local Agency Was Notified of Testing; v u <br /> Name of Local Agency Iuspcctor(fpraent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Co any Name: — C&i v.rl <br /> Tochnician Conducting Test; JDA1% lien P^A <br /> Credentiah: icense o or SWRCB Licensed Tank Tester <br /> License Type: p t v"5"]rA VS a License Number: <br /> Manua turer Trainids: <br /> Manufacmer colnp-0-020us Dam Training E ares <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass FW Not Repairs Component Pass Fall Not Repairs <br /> Tested Made- T Made <br /> e µM- <br /> C- iI X <br /> G X <br /> `tU 10e, <br /> C40 4 z fS, <br /> ;L <br /> If hydrostatic testing was cribe what was done with the water after completion of tests: <br /> c.► s `�"�'• t i.< b...4 G.M� a e•• <br /> c, l V G <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fechr s this document are accurate artd ire full compliance with legal requirements <br /> Technician's Signature: D$ W V fj�G <br />