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Cdn�SX <br /> ata x2 est�tn Report Form <br /> swRca,r <br /> �J SeCriri[��X'� >Etix1� � g <br /> M=VALLEY CONTING <br /> AND GEMERAL UNG! 9892 Cm Lie#. 920085f` <br /> 1497 BRONCO DRZVF,PLUMAS LA"CA.95961(534)749 48S C3� <br /> F,.MATL:Mwalle.consultin(R�sbcoobal net <br /> I. �A�, oR1►xATION <br /> Iktto ofTesiSng: 7126!1418 <br /> Facility Mame FLAG CITY AMPM <br /> Facility Address: 14931 FI.ACi.-vry 1T v1 <br /> Fnvility Contact: Tr3N`t Pltane: <br /> Date Local Agen Was Notified of Testsng <br /> Name ofl.ocsl Agee r(f en[daring teslerT: <br /> 2. TESTING CONTRACTOR INIiOAMATioN <br /> Cam any Name. MW tlalley Caasntting <br /> Technician Conducting Test r;sen Hastse 8155494 <br /> Credentials: CSLS Lieenaed Contractor <br /> License Type: CLASS A License Number.924985 <br /> MsngC�tut+erT inane <br /> Cam nn6n s Data in ices <br /> INOON TS-STS 31912419 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pik" Fail <br /> 'dNot Repairs <br /> Component Pass Fan Not 'Repairs Coma A <br /> Tested Mzde Tested I 114adt <br /> 87 STP X ❑ ❑ ❑ DISPENSER 9-10 X ❑ ❑ ❑ <br /> 89 STP x ❑ ❑ Cl- DISPENSER 11-12 x ❑ ❑ ❑ <br /> 91 SIP X ❑ ❑ ❑ © © ❑ <br /> 87 PRODUCT LINE X ❑ ❑ ❑ ❑ 1. ❑ ❑ ❑ <br /> 89 PRODUCT LINE X :' 0 ❑ © ❑ - ❑ ❑ ❑ <br /> E 91 PRODUCT LINE x ❑ ! ❑ ❑ ❑ ❑ © D <br /> 87ANNULAR X ❑ ❑ ❑ © ❑ <br /> 89191 ANNULAR x ❑ ❑ ❑ ❑ © i ❑ ❑ <br /> DISPENSM 1-2 X ❑ p p ❑ ❑ ❑ <br /> DISPENSER 3-h ❑ ❑ 11 ❑ 11 <br /> DISPENSER 5-6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 7-9 X ❑ ❑ r, © ❑ <br /> If hydrostatic testing was perfonmed,describe what was dome with the water after completion of tests: <br /> Water wiH be removed from A tested containment sumps and t"sitered throu <br /> a charcoal activated filtration $teas and returned to our on aboard storage <br /> Tank. <br /> CERTi ICAMN OF TECHMCIAN RMPONSMLE FOR CONDUCTING THIS TESTING <br /> Tb the best of w knowtcd94 the jaefs$rated In fhls docummi an accarate and In ja17 comptlance with legal requ&em encs <br /> Tedwicisn;s SigQ re.• Data ¢$ <br />