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01-20-'05 15:37 FROM- <br /> @ �%J -0� v•� T-614 P009/019 F-545 <br /> SJlRCB, MAY 2002 J 6 �pUS <br /> 19 <br /> Secondary (�ontiamment Testing Report Form — FINAL DRAFT' <br /> Thsiform is intended for use by contractors performing periodic testing of UST secondary comtalmnent systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILI'T'Y INFORMATION <br /> Date ofTcsting: /-•.yam• <br /> Facility Name: PG <br /> Facility Address: ,5/10yxp <br /> Facility Contact: y722Ck70-Y Cecr 4 ?/G4 iC/v Phone: 2+09'9r'>y <br /> Date Local Agency was Notified of Testing: /�- 2- o v <br /> Name of Local Agency Inspcetor(if present during testing): .fie <br /> ecu- est <br /> 2. TESTING CONTRACTOR INFORMATION DRIVE <br /> Company Name: ACCU-TEST 1 <br /> Technician Conducting Test: ELDONHATHAWAY S30 <br /> Credentials: (] CSLB Licensed Contractor 9(SwRCB Licensed Tank Tester <br /> License Type: <br /> License Number: 1002 <br /> Manufacture Trainin. <br /> [vlangfachtrer <br /> Cpmnonc t{s) Date Training Fxroires <br /> sw <br /> 3. SUMMARY OF TEST RESULTS Net Bepalis <br /> Not Repairs Component Pa" Voll Tasted Mede <br /> Component Paso ran Tasted Made <br /> 11 L1 Ellc �y. El ❑ ❑ <br /> �z ❑ ❑ ❑ ❑ ❑ ❑ <br /> QN/ly/rvf Acd ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �%G / ❑ 13 Elx B ❑ ❑ 11 <br /> 2r El El o1:1 <br /> ❑ ❑ 111 t� ❑ El ❑ <br /> ❑ ❑ ❑ ❑ # o P ❑ ❑ ❑ <br /> ❑ ❑ ❑ ur A.3 u e ❑ ❑ ❑ <br /> azo ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe What.was done with the water after completion of tests: <br /> WATER WAS PROCESSED <br /> CERTIFICATION OF TECHMCL4N RESPONSIBLE FOR CONDTTCTIN THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in ftdl compliance with legal requirements. <br />