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f <br /> sk �� { i ♦ i REC" EWED T {t e }�;-. •aA t'` B Y t { e - k Y 'M 1 4� } .. "^2R 4 {a <br /> b <br /> "• µ�A- ri yi k . c i n • t h�t. µ� k+ip�r >i x i r y i s 'A' -^ <br /> EC2012 <br /> ,,.,_, _ .. 1 + <br /> ENVIRONMENTAL LIJH , <br /> ' S)RCB,Jauuaty'20:02 PERMIT(SERVICES Page of7' . <br /> Second i t Co�tTMt Tei g Rep'orlt Form �eser�din� <br /> phis form is intende4Tfor tlse bye contractrirs petf�trm ng erFod' test ng of UST secondary containment systems. Use the <br /> appraprtatpages of this �t m Ta rej3br telltsdora»tjrtentr 7estec� The'c7�mp�etd fbrir'i,written test procedures,and <br /> it is es7s�' app c e�Y z 3Ct a To 1h: a�rlrty oii�riei��o eratb3fof' ubtriz Cc31 to th 7&Wregul616)1y-agency. <br /> F_uatlttyl�7�rne _ •- ,--� .. .: - _ <br /> e afTesttng• 12- <br /> S!- <br /> Date <br /> s:Date:Local Agency Was Notified of Testing <br /> [-Name-of Locat Agency Inspector(f present durtng.xe <br /> _ twe.ra <br /> Company Name: E.1 i4ea <br /> Techtucian Conducting Tesf; - <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: . ('_.:. LiGens Number: <br /> Manufacturer Training <br /> Manufacturer Com orient s Date Training Expires <br /> 3. SUM,IYIEARX.;OF TEST RESULTS <br /> Prior Re.airs; <br /> Component Pass Bail. p Component Pass Fail Not Repairs <br /> Tested' ;Made Tested Made <br /> �7 o ❑ ❑ ❑ ❑ ❑ <br /> u ❑ ❑ ❑ o ❑ El <br /> ❑ o ❑ <br /> D. ❑ a <br /> ❑ ❑ D ❑ ❑ ❑ ❑ p <br /> Q ❑ ❑ ❑ ❑ C7 . <br /> ❑ ❑ ❑ p 0. . ❑ p <br /> a El ❑ ❑ 01 ❑ D. <br /> El❑ ElEl ❑ ❑ Q ❑ <br /> ❑j ❑ 1 ❑ I ❑ ❑ o ❑ El <br /> If hydrostatic testing was performed,describe what was done orifi} the wafer after corripleton of tests: <br /> Kew <br /> �...– <br /> _Toteh-es?o my n_ <br /> s a e`Ir-' are accura e u comp once ora ego re uuements .._ <br /> Technician's Date: <br /> - - - - - - - t <br /> h-.:�7. <br /> f <br />