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XAWRCB, January 2002 <br /> D <br /> ' FINAL DRAFT- <br /> Paof 7 <br /> Secondary Containent 'Westin JAN 13""'20-01 <br /> 77;is form is intended fvr ure by contra_:,rs er orr.:i; g Report Form <br /> a ry ric:te pag r P periodic testing of USTsecond� ENVIRON�M NT EALTH <br /> PP P es ojt.:is form to repo:r_s::!ts or a',''c �'containr��. <br /> priruoutsiron:ICS IS(jt n1'- 1 f vr''Pvnents tested The cora feted j � '! �/ ��'ES <br /> Pr tccrb c.}. srrf:;:a ce rntii 't: P ornr, r+r �1' <br /> facilih Own-r. n'subm '�'s. rnd <br /> �.z s r - _ L YFAC:ILITi' lr�h <br /> facility carne: -�- xUg tiIA1-10ti <br /> FaciliryA.:.:.•ess!J � - - -. .. - `�-_r- <br /> �l �- Date ofTestin_: �_eq " I <br /> Facility Contact: 'a <br /> Date Local Agency was Notified of Phone: <br /> Name of Local Agency Ins ecty <br /> 4� r -�:e!• <br /> p r - t during <br /> ='. TESTLNG CO`TRAC =i <br /> Company Name: C TOR I1�FORti'L�TIO�I <br /> Technician Conducting / /���/� �Gf� O/✓ <br /> Test: <br /> Credentials: 'CSLB Licensed ;,actor —_--- <br /> License Type: v . ❑ S%k RCB Licensed Tank Tester <br /> License Number: 9 <br /> Manufacturer Tminin? <br /> Manufacturer -- - -- -- <br /> Trainir� Expires <br /> r <br /> 3. <br /> s <br /> ) <br /> I <br /> r <br /> OF TEST RESULTS <br /> i Component I I of ' Repairs <br /> Pa:,, Fail� P rs <br /> 7s` Tested I :,lade <br /> s P 2— <br /> Wei — I� I component Pass Fail ; Ot Repa <br /> rade '+ <br /> 1 ❑ I Tested I iLlade <br /> ,� , _� I ; ❑❑ x-11 ❑ ! ❑ ❑ <br /> --I 01f ❑ 1 ❑ ' 0 1I El❑ — <br /> ❑► ❑ i El ED <br /> Z ' I ' <br /> Li <br /> Li <br /> ❑ I ❑ I ❑ uu� ❑ ► ❑ � <br /> -n-- - -----► ❑I ❑ i ❑ �-� ❑ ❑ I ❑ I <br /> Comments — Ifbydrostatic tcstin•• ;:a; -� ' , a-- _t <br /> - �cdormcd.ascribe chat «as d0nC s;i:.%t the�vaterafterc,-:ci:^ _-- <br /> 1 •mon of te,t�s). <br /> f <br /> ---__ — <br /> CI?ItTIFICATIO:\ OF 1'ECIL\ICiA.`'i_s�f rr ci:rn'snjNn;urJtickno��'lerhe, tL•e f-:cy:r��:�r�lJ-in-�1C!RESPONSIBLE <br /> ---�nr>tc ct�O-��ONDU oTEjGe1I TESTING <br /> the <br /> ,\Gtic best (IIcasc Print) ar �rcrutanthis ciq dlPrncs. th <br /> -- ' <br /> ,u!r�y:rircm�n/` <br /> ccltnici;tQ's Signaturc: <br /> �.. �.... .. <br /> 7 <br /> Date: 7 <br />