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FROM :Donlee pump co. • <br /> FAX N0. :2095379398 dian. 27 2009 01:50PM P2 <br /> i- <br /> "WRCB,January 2002 Page!„,or-�. <br /> Secondary Containment Testing Report Form <br /> 7 hlsJurm is inlended fbr use by t'amraetors peryorming pertadic testing of(/3%'secronelGry carotulnrovrM syf7ums (GVe the <br /> appropriale paves ofthis form to report resuhsfur all components tested The compleodfurm, wriaon test provedartat, and <br /> printokis from tents(If applicahlc),should be provided to the facility ownerlopet-alfw%for,ubminu!to the ick-u/regblGlul;v agency, <br /> 1. FACILITY INFORMATION <br /> Faclliry Namb <br /> uc! ity A = s Date ofTestlny;1p�V �_.. ..__. <br /> rose;% — <br /> Date Lotu1 ntactl ns Notlfl/ — — — <br /> .._.dd... .._ <br /> -----lA eno W <br /> F'ucilit.''C g Y.— ed ofTestln _ <br /> Js I- <br /> 'Jame of Local Agana Insactor(tf present dartn testinW: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompenY Name, D04kp - <br /> u1, mc.lan Co_nJuctlnQ T'aec •k P l <br /> --.. <br /> Credentials i I C81,B Licensed Contractor I I SWKS Li�ensod Tank Tester <br /> License T n; I Liccuse Number: <br /> Ma1rr(ectrrer Tratalaa <br /> Comsoneanw— Dtun Tndnlnt_BH Ip ros <br /> I SUMMARY OF TEST RESULTS <br /> (Ilelponeat <br /> JIM Fall Nut RYpa4a FeN CeetpteaW Not 1(epairs <br /> parr <br /> .....—...-- ---.— .__.._ 7•eawtl Mrde Islted Made <br /> QIJ1Kp. ovv .—.. L III fa ---.. .._ I':! LI LI I <br /> �e�pl i.lta3i fiJLY__... _n .. <br /> n. -- --- .... -- Ll I I 1'.1 I_I <br /> Q1..Uk.Lt .. ........ K ..n n G ❑ Ll 1.1 rl <br /> fQl....96.1 _lntilEet,. i4, LI ._ r 1 u n . n i I ri . . <br /> tllAe. .....—..—. u LJ lJCI n ...._n._ <br /> 11 II L LI <br /> LI LI, Ll : 1 <br /> LI <br /> FI <br /> I...I I I IJ 1.1 <br /> to. od . ,t}. ` bli cel 0 �qt/ ��1�.�.. .._—_ s: <br /> IYhyd�toatutic�testlnp was'erfttrmed,describelbe wh�ne with the <br /> eftor,ompktlon nftest - <br /> -- icI uw P <br /> S- �a of 1��: .rn....5�.—_.. ..—. .— <br /> ('1?R'PIP'I('ATION OF TECHNICIAN 111,16PONSIBLL'' FOR CONDIJC I'IN(J'1'Ii1, Trw9'1'ING <br /> To the besr djrr{V kNowlt *,the fiku waW Jn lisle ducnteew are aetwnrte and/n fall Compliance Iwilh layulwret�NdrameMa <br /> technician's signaturm.f Date: ``o U <br />