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t <br /> • Lo <br /> ACDWAUgvst2003 Alm 7 206 <br /> I <br /> coma Ca tainment Testing Report """"A*� bts <br /> This fonn is ireended for use,6y impectlon swf�'perfor mgj #' durft Puollmon o,{'GCS7 seea�ldAty�Gd+rptairune�at syJterns.' Use the <br /> appropriate pages of thts form to report results for all c tested Ae completed foram wri t n 4gst procediersea.and printouts, om tests <br /> (f applicable).Aall be used in evaluating the installation a equipment azul repairs to""sting equipmeW. <br /> ]. FACIA • INFORMATION' <br /> Facility Name .— Date of Testing: -� <br /> k'acii�y Address: <br /> I~acility Contact: t Phone: rr / <br /> Date Local Agency Was Nottfled of Testuag: — <br /> Mame of Local Agency Inspector(pretsent during les <br /> 2. TTsTnvG+cCTOR INFORMA'ITUN <br /> Company U.S.T.Compliance dw <br /> �Technician Conducting Test: Tony Fontana I McCarthy G� <br /> Credentials: x CSLB Licensed Contractor $WX03 Licensed Tank TesW <br /> License :A Gen.Eng. #846288I License Number: <br /> Contra k's rtungptturerTraini�u <br /> Mmufactgrer Cam s} Date Piining Expires <br /> In-Con TS-STS <br /> 2-22-2018 <br /> • I q <br /> 3. OF TEST RESULTS <br /> Component .Pass Fail T I d Ae <br /> "in Component ftos Fail Not Repairs <br /> Tested Made <br /> ❑ ❑ ❑ ❑ ❑ a <br /> t ❑ ❑ D ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> l ❑ ❑ ❑ ❑ a ❑ <br /> t`" 6d" ❑ ❑ ❑ Q ❑ ❑ <br /> • ❑ ❑ ❑ C) ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ allu <br /> ❑ ❑ ❑ ❑ ❑ <br /> If hyclrasWW WUM was p &nwd,deNcrre wig ne with tate water aft completion of tests: <br /> LeLUM soludoon taken with us to use at nextfi <br /> hispm*es signature: ,. —7 .. l t.�► <br /> Date: <br />