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a <br /> S WRCB,January 2002 Page_of _ <br /> Secondary Containment Testing Report Form <br /> This form is lraendedfar use by contraclors performift pertodie sesdng BUST secoatf<ayeantalnarent syurems. Usr the <br /> appropRau pggrs cf lhis form to npar rendes for all compamnu teased The compteiedfa m,wrlUca tat procedures,and <br /> prlatouts frac tars(ifapplicable),should bt provided ro rhe fadlly owner/operator far aubminal to she lond regulatory agenq <br /> 1. FACELMV INFORMATION <br /> Full' NameI Date ofTestin : -O <br /> Facility Address: O Y t143r <br /> Fwdity Contact: C W YY)E Phone: CrA <br /> Date local Agency Was Notified of Testing: / <br /> Name of Loral Agency last m-W Wpmscnt i wft 1"Ung): <br /> 2. TESTING CONTRACTOR INFORMATLON <br /> Company Name: Triangle Environmental,Inc. <br /> TOCIA-deum Condlrcdng Test: <br /> Credealials: VCSLB Lkensed Contractpr ❑SWRCB L ceased Tank Tester <br /> Ll'c—s 'type: "A","C-10","I3AZ" LiaaseN=- bc-r: 673971 <br /> Msaafactorer Tralninz <br /> Mamrfadura s Date Tram' I5 "res <br /> 3. SUMMARY OF TEST RESTS <br /> Component Pus Fal Not Regan Complacat Para Fall Not Repairs <br /> Tested Male Tested Made <br /> W—Fitt- LL ❑ ❑ ❑ ❑ ❑ Cl ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> et a ❑ ❑ ❑ Cl ❑ ❑ <br /> a ❑ ❑ ❑ ❑ 0 ❑ <br /> ( wi�w Pv✓- -vim - Lel, d a ❑ 1 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ b ❑ a ❑ a ❑ <br /> ❑ ❑ a ❑ ❑ ❑ ❑ ❑ <br /> a ❑ ❑ a ❑ 1 ❑ 11 <br /> ❑ ❑ ❑ a ❑ 1 ❑ 1 0 0 <br /> ❑ ❑ ❑ ❑ ❑ 0 0 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> if by&wta*testing was performed,decalbe what svgs done with We water'eff canpletion of lists: <br /> rp� r Yl t� <br /> CERTIFICATION OF TECHNICIAN REMNSOU FOR CONDUCTING THEE TESTING <br /> To the beat ofnw bwwMfZ4 rhe facts stated In aU dxwnmt are aawrale and InfaU CMM laaoe rrtrh k9d Fegrsirearents <br /> Toolu idaWs Signature: <br />