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SWRCB,January 2002 Page 1 oft Secon&ry Containment Testi This form is intended for use by contractors performing periodic testing of UST recon c PI Ulm systems. Use the appropriate pages of thisfoi.v to report results for all components tested. The JQ+gl ed' a, written test procedures, and printouts from tests(if applicable), should be provided to the facility own, fopeF7b},F ? 209@al to the local regulatory agency. 1. FACILITY INFORMATIO' 1RUN;ti9Pi Facility Name: / T uClGiYr� g: /Z 119,103 Facility Address: ;2-�f / 4 - f4 1 oS�j S oG1c or Cq 2d s Facility Contact: Phone: 2-----7 f-2X74- Date Local Agency Was Notified of Testing: /2, /d (J 3 Name of Local Agency Inspector(ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: F? , t ou c c + ry Technician Conducting Test. a a , •,H F• " t hI Y Credentials: ❑CSLB Licensed Contractor RtWRCB Licensed Tank Tester License Type:et44X- TyS ✓ License Number: V _11Zp .�Ge�S2t(6YJozu1 Manufacturer Trainine Manufacturer Component(s) Date Train;— Ex fires 3. SUMMARY OF TEST RESULTS Componentp� Fall Not Repairs Repairs Tested Made Component p%� 'Fall Tested Made t-y},1-. El El 11 El ❑ ElyvNµlu e. IL, G. ❑ ❑ ❑ ❑ ❑ ❑ ❑ .14 C t av, .t...1- ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sc e- y,Aa N * ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ps RIO I0'L ❑ ❑ ❑ ❑ ❑ ❑ ❑ U b C4 1 ti ❑ ❑ ❑ ❑ ❑ ❑ ❑ LA f) X31, q ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Tt$� L,JJ $u. pI i•eJ Afteeyey' -�y' t`Pttio ail„G {� CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,thefacts stated Inthis document are accurate and In full compliance with legal requirements Technician's Signature: _ .ti- / Date: