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06/03/2004 07:58 20946834':Iq SWRCB, )atntary 2002 FIFTH FLOOR Secondary Contairilment Testing Report Form PAGE 03 Page ` of This form is Intended for use by contractors perfor ring periodic lesting Of UST secondary contairunew syslems. Use the appropriate pao-es of this form to report results for all compo.,rrar tested Tlee completed form, written test procea4ees, and printouts ftom tests (f appLcah&), should be provided to the facility owner/operator forsubmittal to the local regulatory agency - 1. FACILITY INFORMATION Facility Name. Facility Address: Facility Contact: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (f present a 2_ TESTING Company Name: L. J T "E. - Tcchnician Conducting Test D a ti Credentials. CSLB Licensed Contrac License Type: 73 C -) D q(- �+A Manufacturer T A a- N a. Datt ofTestine- i _ n.4. Dr Phone: (7,—/- TRACTOR 'E't- TRACTOR INFORMATION Co nl e O SWKTB Licensed Tank Tester License Number: (1 0 Manufacturer Training '- CITMMADV "IV'TL'QT D1u cTTT rc Daze C Component Pau Fail Not Tested RcpAin NL1iie Compoaeat Not P:n Fi,7 Tested Rcpain Mede Lj e a. o' U! 0 ❑ ❑ 0 D I D ❑ ❑ ❑ 1 0 ❑ 0 0 D ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 1 0 ' D o "_ - ❑ 0 G ❑ 0 D D 0 D D 0 0 — ❑ 0 0 0 ❑ ❑ ❑ ❑ D Q n D ❑ ❑ ❑ ❑ o o 0 0 ❑ I ❑ ❑ _ ❑ 0 D 1 ❑ ❑ If hydrostatic testing was ptrfornied, describe what was done with the water after completion of tests. CERTIFICATION OF TECELVICIA,N RESPONSMLE FOR CONDUCTING TMS TE+,.TNC- [a lite bPSt of ntf 7tnowlcd: e, thef.�5s statcd in this document are aceyraie and ire full compliance with legal rrquiremems J / Technician's Signature: Date: