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03/04/2003 16:11 FROM D " S DRAGLINE SERV. INC. TO 4683433 P.02 <br />yYli:: <br />.rll <br />SWRC8, January 2002 Page of <br />Secondary Contaim.ment Vesting Report Form ' <br />llis form is intended for use by contractors perfomlirig i)eriodic resting vi US7'secondary cgntainment systems, Use rhe <br />appropriate pages of this form tO report results for all components tested_ ne complexed f vm written rest procedures, and <br />panto= from testi (if applicable), should be provided to the facility owner/operator for submittal to the local regularory agenev. <br />I. FACU-M INFORMATION <br />Facility Name: f vt c - p I Date o T esdrtn: 7 9 -r <br />Facility Address: <br />L. <br />95 9 <br />Phone: <br />Dace Local Agency Was Notified of Testing <br />Name of Local Agenev Inspector (if present during iesttngj: <br />2. TESTING CONTRACTOR LNk'ORI MA'TION <br />CO=Pany Name: <br />Technician Conducting Test: <br />Credentials:. SLB Licensed ContacSWRCB Licensed Tank <br />License Type: A . 1.1,-7 -4 C 57 ' ;.:cense Number: C < <br />xffulacturcr _ Component(s) <br />R <br />-7n t`on TS - S75 ! (At <br />FEE <br />�I SUMMARY OF TEST RESULTS <br />Date Train/ <br />Component Pass <br />Fail SOC Repairs Compeamt Pass Fail Not <br />iTrsted I Made Tested <br />Repairs <br />11de <br />t ' r� ! <br />91 ?C <br />9_ <br />0 <br />r <br />OA I <br />o <br />/ 0A /x I <br />f <br />..1 <br />4+ 9 <br />If hydrostatic testing was performed. dcscrioe what was clone with the water after completion of tests: <br />CERTIFICATION OF TECBNICLAti RESPONSIBLE FOR.C+ONDUCTOiG TMS TESTING <br />To the bestaf my knowledge, the facts srated in this document are accurate and in fuU cornpAfar cz with legal requirements <br />Technician's Signaritre4lC� —V <br />BaEe- <br />