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+ ACDEH,August 2003 <br /> Page of <br /> Secondary Containment Testing Report <br /> This form is intended for use by inspection staffperforming testing during installation of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed forms, written test procedures, and printouts from tests <br /> (if applicable),shall be used in evaluating the installation of new equipment and repairs to existing equipment. <br /> 1. FACILITY INFORMATION <br /> Facility Name �=Z ,,rte ryk, T �� �-� ��J Date of Testing: <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(present during testing: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company U.S.T. Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana/Bill McCarthy <br /> Credentials: x CSLB Licensed Contractor <br /> x SWRCB Licensed Tank Tester <br /> License Type:A Gen.Eng. #846288 License Number:92-1153/91-1151 <br /> Contractor's Manufacturer TraininLy <br /> Manufacturer Com onen s) <br /> In-Con Date TrainingExpires <br /> TS- STS 3-20-08 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs EEDD <br /> Tested Made Component Pass Fail <br /> 11 El <br /> ti�����- ❑ ❑ ❑ GIQ-C � �� ❑ ❑ <br /> 11 El <br /> �' ! ❑ ❑ ❑ SOC „cr CY2 ❑ <br /> 87 ,�=►tet ''�'S� ❑ 0 ❑911 WE10 ❑ <br /> -� ❑ ❑ ❑ ❑ <br /> ❑ ❑ <br /> 0 11 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water placed in 55 Gal. drums & left on site <br /> c <br /> Inspector's Signature: 4�1 !/ p <br /> Date: ® '/0-�,� <br />