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- Page—!—Of <br /> Z <br /> swRC6, MAY 2002 <br /> ment Testing Report Farm - FINAL DRAFT <br /> Secondary Containt systems. Use the approp...,..,,,, <br /> performing P <br /> This form is intended for use by contractors r eriodic testing of UST secondary containmenu <br /> componentsstested The completed form, written test procedures, and printouts from tests <br /> pages of this form to report results for all <br /> (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. -- . <br /> 1. FACILITY INFORMATION ENVIRUluMLi`Y'i <br /> Date of Testing: S <br /> Facility Name: 68-5 n e OT <br /> Facility Address; g,27 /� ,Lft++ iG G F1 9s X31° <br /> q EA��' 06 E.�i r <br /> Phone:�p�- �,�.$—7•��z. <br /> Facility Contact: )C C VV, <br /> Date Local Agency Was Notified of Testing: 1 - k S- o`K- <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ACCU-TEST <br /> Technician Conducting Test: ELDON HATHAWAY e S ,3 Z O 7 SY— /9 <br /> Credentials; ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Number: 1002 <br /> License'Type; <br /> Manufacture Train in <br /> Manufacturer <br /> Comnanent(s) Date Training_,EExnixes_ <br /> i t S ► <br /> sA <br /> N stirs • I� <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Not Repairs Component Pass Fail Not <br /> Made <br /> Component Pass Fell Tested Made <br /> yyk/rrs � / ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ct`/'�avler e�z 2 ❑ ❑ ❑ ❑ ❑ ❑ <br /> El <br /> ❑ ❑ El El <br /> El 1:1 <br /> ❑ ❑ & ❑ ❑ ❑ <br /> El El <br /> Q4- 1-2C 3-q El ❑ ®' ❑ ❑ ❑ ❑ Els_c 7- El El 12 ❑ ❑ ❑ ❑ <br /> El <br /> ❑ ❑ ❑ ❑ ❑ El 1:10 <br /> ❑ ❑ ❑ 1 ❑ <br /> If hydrostatic testing was performed, describe what was done with the water,4fjpr completion of tests: <br /> WATER WAS PROCESSED <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements. <br />