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11 Ir! ;L <br />ACDEK Augwt. 2003 DEC 17 2013 P Oge A— of <br />t+condary Containment Te ting fQ NMENTA,I. <br />i :;�OPM is intended for use by inspection sraffperformt* jeyo4g during installation of UST secondwycontainment EPARTMENT <br />pria system. e die <br />pages of this orm tore rt results ar all eom r78tNs tested The eompletwelf-wM-T, w)-irro" VS <br />(1jaPPl;Ca4qe), shalt be used in qvaluat&xg the "st"1440A of new 6"iPmOnt and rePairs to exkring equipment, <br />and' 70"a" <br />FACIffy MORMAITON <br />Ga . T, <br />6W_ <br />Dam of Timing: <br />gF:arjoy Address: <br />o <br />facility cont <br />AM Phone: <br />Agency <br />Was <br />Notified ]dam <br />:: Inspector �c W7 <br />Iocal Agency Was Notified of Testing <br />o of Local Local Agioney Inspector (present dswing tevtjrg)- <br />2. TESTING CONTRACTOR INFORMATDONK... <br />any <br />Co UIS -T. Com fiance Testing Inc. 7 <br />Techikian dWting Test Tony Fo <br />BW MQC&Ihy <br />Te <br />iccood Contractor x SWRCB licensedTank Tester <br />Liccxtw Type: A Gen. En #946288 <br />In -Can TS- STS Data <br />ICCTpr.T4 9"N _;4T IMLV-An-E <br />Component <br />I <br />If hydrostatic testing was <br />3. SUMMARY OF TEST RESULTS <br />Pass <br />Fad <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />ON <br />K <br />V I <br />El <br />E <br />❑ <br />Ef <br />- <br />Lj <br />descrfl)e what was done with the water after completion of tests: <br />k4&A <br />MJIM�M_Mz <br />MMII�� <br />NOMM <br />ON <br />F RV :VT TA -. . " Ti'.T <br />TT/L13 _�'Vd <br />