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MAY-03-2007 08 :28 AM GETTLER-RYAN INC. 925 551 4770 P. 03 <br /> RCB,January 2002 <br /> Secondary Containment -resting'1i Meport or <br /> perindit,tes-,m? f <br /> This form 0 Intended for use by contractors performingq0 UST secondary containment systems. Use the <br /> UppropriatepagO Of thiSJ41'M to rtporr results for till 77ircempletedform, written test procedures, and <br /> printouts from tests(if applicable), should be provided tolhef4Cility,)Gi,ner'opertitorfor submittal to the Ideal regUlatary agency <br /> 1. FACILITY INTORMATION <br /> Facility Name: Date of Testing- 6P Y <br /> Facility Contact; Phone: <br /> Notified of Testing: <br /> Name of Local Agency I!2ector(Itpresent during testink <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com ppj Name- <br /> Tachnidan C Tog: To*Teeter <br /> Credentials: CSLB Licensed Contractor SW RCB Licensed <br /> Li Typo:C57. B, C61/D40. RAUZ A HIC. Cjj License Number. 2207 <br /> [ac mer Tr <br /> MR-Mduma 7- COMEon a Onto Ti2ining EMOM <br /> C' rf <br /> 3. SUMMARY <br /> OF TRESULTS <br /> Not <br /> Not <br /> omRopdn <br /> V <br /> Component pan po <br /> Component Pass Fall TMR111�� ll maw <br /> 1 ested — & <br /> ------- <br /> If hydrostatic testing was performed,describe what was clone with the water After completion of tests: ___ <br /> CERTIFICATION OF TECHIN ICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the beg of My knowiedgu, flig faca sjurej in this document are aremate and in full compliance with legal orquirements <br /> Date:- <br />