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SWR-,B, January 2002 Z <br /> Seeondar Containment Testing Report Form uu''nn <br /> This form is inter daifor use by coirtrr�ctors performingperio&c testing of USTsecondmy snntainment s' Lj.0 4pig <br /> appTppriate pages of`this form to report results far all components tested The completed form, wF**#RAW and <br /> printouts from tests(if applicable),should be provided to the facility awwr/operator for submittal T�v. <br /> Or C <br /> 1. FACILITY INFORMATION <br /> FacBity Name: k !LS L.l u o E = �. ! Date of Testing. -3-/<(cA <br /> Facflity Addrm-. l y c, 0,4C.i FOC N!t-? 5°7) f Z-5 C'4 t-0-lam: 0 C--,` r <br /> Facility Con tad: . Q a.$,K c+ -�fte.^� s Phone: ; c � � �' ; � _ 7�-7 <br /> Date Local Ageuey Was Natfied of Testing : ;:,,/5L,4(/e . <br /> Name afLocal.Agency Inspector(if prevent Armg"testing): 5, C. <br /> 2 TESTING CONTRACTOR INFORMATION <br /> Company Name: ` <br /> Technician Conducting Test: l)L v r+ti L <br /> Credentials: CSLB Licensed Caa=aor L SWRCB Lizased Tank Tester <br /> License Type: e� I.tcaase N mber: <br /> Maaufa��ear Tarni�imr� <br /> ?'+ anl6chm C a Date Tr63ing E <br /> 3. SUAU A,RY OF TEST RESULTS <br /> Not Co,upa�t Paas Fag ,�eftd � Component Paas I Fad "at�exWd Made <br /> 4 �L F(Lc J�nX ❑ ❑ ❑ ❑ ❑ <br /> 7 1 �7C2 =/LL 0 � ❑ ❑ ❑ _ ❑ <br /> on 0 ❑ <br /> ❑ ❑ C7 0 ❑ ❑ 1 0 <br /> ❑ ❑ 0 ❑ ❑ 0 ❑ 0 <br /> ❑ 0 ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V 0 ❑ ❑ ❑ ❑ 0 0 <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ C <br /> ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> 0 0 ❑ ❑ 0 ❑ <br /> cl <br /> If hydrostatic testing was performed, desczsbe what was done with the wa+W after completion of tests: p <br /> CERTIFICATION OF TECIMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest of my knowledge, tke fay stated in this doc ment are accuratc and infnfi cantpliance with;legal regubT nests <br /> Technician's Si€osamre;- LL X79 Ila <br />