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SWRCB,lanuaty2002 — Page L-ofZ <br /> Seconftry Containment Testing Repa`rfForm <br /> Thisforin 13 imendedfor use by contractors performingperiodic testing of USTsecondary containment systains, Usethe <br /> appropriate pages of tbisform to report results for all vomponents tested Tire completedform, written teat procedures, and <br /> printoutsfrom tests Wapplicable),should be provided!o the faaW-owner/operator for submiltalio thelocal regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name. T3 9: • u 416,-inc? Date of Testing; /2 / O <br /> Facility Address: f-+-f i 64 / i dSq <br /> Facility Contact: <br /> 12-0 r f r'YY!Y! Phone: 20.7 <br /> Date Local Agency Was Notified of Testing: /2,//d/j/9 <br /> None of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompaoyNante: <br /> Tecbniciao Conducting Test. P v.',t w.•,.n F, u.C er j"• <br /> Credentials: ❑CSLU Licensed Contractor WRCB Licensed Tank Tester <br /> License Type:%a..et K— 7�5 ✓ - - License Number: �ti j�fj �G$ •�Zt([,fja�u <br /> Manufacturer Training - - <br /> Manufacturer : Co anent s DatoTtninin Exires' <br /> 3. SUMMARY OF TEST RESULTS <br /> ' Not Ripairs NM Repairs <br /> . Caspoaaot Piss Fail . . Canpoaeat,. Pan].Fail <br /> . Tested �Made Tested Made <br /> 14yiti,nlri. ��. 1. ❑. ❑ © a ❑ a 1 ❑ <br /> u.lu ' tc. '7. ❑ ❑ ❑ ❑ ❑ Q 1 ❑ <br /> r AAAA1 P10AAAA -* ❑ ❑ ❑ ❑ ❑ D ❑ <br /> `ter . A 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> IA LtZ ❑ ❑ ❑ ❑ ❑ ❑ Q <br /> LTJ e, 3g- ❑ Ell ❑ ❑ <br /> ❑ ❑ ❑ CJ. ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was perfonned,descrlbe what was done with the water after ootnpletion of testa: <br /> 145-' -HLA i Su P� 1•t, �w� 'l�t'loVnif t{� 1'tM` %('LfCQ tete i<+�.o-Q•-LOwD I J1t4tt0— AW9 - . <br /> CERTIFICATION OF TECHNICIAN RFSPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my Anowledge,thafacts statad in this document are accurate and in fuel compliance with legal requirements <br /> Technician's Signature: - +• /+; ' Date <br /> -AJC <br />