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9l55517ft.' Line 1 1tEC;E1"4,!'"RD 59 a.m. 01-09-2009 1 11 <br />mo' <br />E � �� � � _ �� N <br />IN <br />C. <br />JAN 0 9 2009 <br />® HEAL v V r,'+..9 i ?'MEfv'`i <br />AGENCY NOTIFICATION SHEET <br />W/O #. <br />L� <br />Notification Date: <br />Notification For: <br />Re nested Test Date: <br />ll��t jC� <br />Initial TestEl <br />Facility Name: <br />/ <br />Repairs <br />Site Name <br />Facility #: �� <br />Re -Test. <br />Address: ��Ip <br />City, State: � i!)77 l <br />�. <br />Agency Notified: r_,ljy7 <br />_� <br />Method: <br />contact Person: <br />Verbal <br />Fox <br />relephone: <br />E -Mail <br />*ax #:aLd2 "uu <br />Confirm Date/ Time: <br />Tech: <br />resting Scope (cMckeNcomponentathstspply) <br />T-27 Back Pressure/TP 201.4 <br />® <br />Tank Monitor Certification <br />T-30 PSI Decay USY TP 201.3 <br />® <br />3-GPH Leak Simulation <br />T-37 Liquid Removal/TP 201.6 <br />Static Torque TP -201.1B <br />T-38 PSI Decay ASY TP 201.3B <br />Drop Tube/Drain Valve <br />TP 201.10 <br />T-39 Air/ Liquid / TP 201.5 <br />Drop Tube OVERFILL TP -201.1D <br />REPAIR SCOPE *svibecomp weaand.Wk0atedrepairs) <br />J'✓t <br />Notification Contact: / Telephone: (925) 551-4777 <br />Scope of Work Contact: Telephone: <br />I •'-1- fiicrra Court, Suite J ublin, California 94569 - (9251 5S1 -7s55 <br />