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{ <br /> SWRCB,Jan <br /> C uary 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ay-c,) h„=6-82(a o Z Date of Testing: l O to <br /> Facility Address:2- 3n J®e_. 1�n,�. t� P v4 . 't 5 3 Z <br /> Facility Contact: (2.�j,au-�- 1-�. Phone: o 8 3 6 8-77 8 <br /> Date Local Agency Was gotified of Testing': Zl v 8 <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:r2°. { 1) �- <br /> Technician Conducting Test: v,'tea.�ivy rj <br /> Credentials: 0 CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type: V— ,�,5}-�V License Number: v-l l?.CU c c, 5a (a c�C122,�--GI`r <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass FailNot Repairs <br /> Tested Made Tested Made <br /> nwu(�� ❑ ❑ ❑ ❑ ❑ <br /> e ca f '�1 ❑ ❑ ❑ t� S` El ❑ ❑ <br /> r i ❑ ❑ ❑ 1Qj &,rrce ❑ ❑ ❑ <br /> -fez ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 3`*3 ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> (A. Lei ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ► -� D eo-jtvtate- "-eS4kje4. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this 49qument are ac urate and in full compliance with legal requirements <br /> Date: lb4lza <br /> Technician's Signature: _ <br />