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Etp3 15: 25 -12e93651543 TCaHMOLOGY PAGE J3/03 <br /> - SWRCB,January 2002 - page of — <br /> Secondary Containment Testing Report For <br /> ?Isis form is oiw for use by contraetc,rs pert perfll"lc testing of UST.wee® cnnrai m lystems. dlse the <br /> 4WPr0 of le,should be s�ded to t� atilt y owner/ eratOr or� al to the local mms testedaand <br /> ►VY <br /> prinrorras from rests(If�qp i 1. P � �' f <br /> 1. FACMM DUVRMAnON <br /> Flcilisy Name ` Ll Of Date of Testing: <br /> Facility Address: <br /> FacilityCant=er" phare: <br /> Daw Local cy Was Notified of Testidg: <br /> Name of Local Agency In or(i ra durtng tasting): <br /> 2. TESTING CONTRACTOR MORMATIOTI <br /> Cowpmn Name. 13r-,z_A, C . <br /> Technician Cando Test 1 f' <br /> C rials: CSLB Urensed Catntractcr S C$Licensed Tank Tomer <br /> License Type: La=w umber: <br /> l�tars r.'�r�ainl>Q - <br /> Nlan> Sct�re3 C ea s Date Training Expires <br /> 3. SUNEWARY OF TSL,'LTS <br /> Not Repairs <br /> Component Pass Fame Tina PAp2irg Component P e 1'sit Tested de <br /> d Had* <br /> r ❑ ® ❑ ❑ ® ❑ G <br /> t ❑ <br /> 1:3 i ❑ ❑ ❑ ❑ <br /> Prol— Lam 7i ❑ ❑ ❑ ❑ 0 d ❑ <br /> ❑ 0 Q ❑ t` � ❑ ❑ 0 C <br /> l ❑ n ❑ <br /> ❑ i1 ❑ ZN e e, Lr �S ❑ ❑ <br /> L" 0 ❑ ❑ ❑ ❑ o <br /> C � 0 0 ❑ ❑ ❑ ❑ '�' <br /> G C ® ❑ LL❑ 0 ❑ a <br /> If hydrostatic testing was e(L desetibe what was dime with the water after completion of tests: <br /> t 4 c �• <br /> CERTIFICATiOPi OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> TO the best ofMY kAWWlemlge,tide fares stated in tots doemment are accurate and in full co pliatwe wUh legal raquirenetnts <br /> Tedmician's Signawee:- I)am' — — <br />