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RPR-28-2006 12:22 TIME OIL CO. 2062864477 P.03 <br /> SWRCB,January 2002 Pape-L-of�1 <br /> Secondary Containment Testing Report Form <br /> Aisform Is inteWedfor use by ow0mcwrs performing periodic testing of USTsecondary containment systems. Welke <br /> appropriate plc afthis form to report results for all components tested The completedfa m,wt'itten test procedures,and <br /> printouts from tests Ofapplicable),should be provided to rhe facility ownerlopw ator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name; "1- L �/ Date of Testin <br /> Faciiity Address: ( t4 W <br /> 1113clutycontact SAM til A Pj Phone cf _ <br /> Data Local Agency Was Notified of Testing: <br /> Name of Local Agency inspe for Cfpresent thaing tesringl_ <br /> 2. TESTING CONTRACTOR INFpRMATION <br /> CompanyName: T)1 CON S� L-t 10 <br /> Technician Conducting Test: 1 K-C- A 121 It,vJ 4 L I <br /> Cmdentials: ❑CSLB Licensed Contractor q SWRCB Licensed Took Tester <br /> License Type: License Number: <br /> anufaatore f, <br /> Manufactluat Co ens Dater ' - Ex iter <br /> OD t - <br /> tic•rte <br /> bV �. <br /> Ci o <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Psact Fait TamRepzirs <br /> ed Component Paas FaR Not Repairs <br /> 'fated Made <br /> a IZ 1JUU+ ArL ❑ ❑ ❑ Lj Cl� ❑ ❑ <br /> _A1 JA <br /> Naf i ❑ ❑ ❑ ILL ❑ ❑ ❑ <br /> i� NaJu ❑ ❑ ❑ eb(L 0 ❑ ❑ <br /> c 7 $4, ❑ ❑ ❑ P_-r—m �j aPd 2 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 1 Q ❑ ❑ ❑ ❑ ❑ ❑ <br /> CA i 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> S to ❑ ❑ �' ❑ Q ❑ 0 <br /> Ifhythostatic testing was performed,describe what was done with the water after completion of tests: <br /> �1ACE1� I bl �A'� b /,8MI. <br /> E-�Z.._.. , Sri <br /> CERTIFICATION OF TECCEMCIAN RESPO LE FOR CONDUCTING THS TESTING <br /> To the best of my Imowledg.;thefacts stated in this does accurate and infuU eompRame xglh legal requirements <br /> Technician's SigtaturM <br /> Date: f 0 d <br />