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CGU �- <br /> FEB 0 9 2007 <br /> S tVRCB,January 2002Page L of <br /> ENVIRODI(ti ENT HEALTH <br /> Secondary Conf6fi&k&fT"g Report Form <br /> This jnrm lr lmandedjor usa by eontroct�rs performing pariodlc tasfing pjl/Slsacondory canfalnmant.rystanu. Use the <br /> appropriniepages ofihisform to report resulrsjar all components tested The completedjorm, written test procedures, and <br /> printouls from l"i,(rjapplicablo),shouLl be prodded to thejacility owne loperatorfor submittal to the local regulatory agency. <br /> I FACILITY INFORMATION <br /> Facilit Name: l t. Data ofTestin : <br /> Facility Address: Lf qM ': <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector({fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CampanyName:RICH ENVIRONMENTAL <br /> Technician Condutting Test: O <br /> Cmdentials: B CSLB Licensed Contractor 0 S WRCB Licensed Tank Tester <br /> License Type. C611D40 license Number: 809850 <br /> i <br /> Manufacturer Training <br /> _ Manufacturer C ne a Date Training Expires <br /> INCON INCON TS-STS <br /> 3. SUMMARY OF TEST RESULTS'' <br /> Component Pass Fail I Not Repairs Component Pau Fait Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ 1 X 1 ❑ 56,.o ❑ 1 ❑ ❑ <br /> R ❑ ❑ ❑ v it ❑ ❑ ❑ <br /> 0 Cl- ❑ ❑ 1 ❑ orz 5PA1 ❑ ❑ j <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> C ❑ ❑ ❑ 0 ❑ ❑ r, <br /> ❑ ❑ -4V ❑ ❑ ❑ ❑ ❑ <br /> 1 ll m ❑ ❑ 0 ❑ ❑ ❑ D <br /> C] ❑ [1 ❑ ❑ ❑ ❑ ❑ <br /> O IT—0 ❑ 11 ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> RECYCLE AND REUSED ' <br /> CERTIFICATIO F TECHNICIAN RESPONSIRLE FOR CONDUCTING THIS TESTING <br /> TO the besr of my knowledge Die cls stated in this documenl arc accurate and in juli complianee wills legal requirements <br /> Technician's Signature: ��i /�/ —(T Date: pl- <br />