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SW14.13,January 2002 'a ge I of <br /> Secondary Containment 'Testing Repo r T HEALTH <br /> 1,11is ficin i.v intended/itr use by contractors per,forrrrirrg periodic testincj of l_eT s'ecom/un,con catruue I��rstcnrs. -se the <br /> appropriate of this farm to report 1'c'.vr1/ts fiw call c•omponerp.v tcstecL 77re completed Jurrn. written tc.vt procedures, and <br /> printorttc Ji urrr tests (il'applicahle), should hey provided to the ficcilitt,on ncr;'operutor for svthmittul hr the local regulatory <br /> I FACILITY INFORMATION <br /> F cilr(y Name < oce ✓ i �t.�✓ �� g ,� Cc> $ — _ 1)tte of 1'estinb 3P) !)'1 <br /> - --- - <br /> Facility Address fit. fP, i -, --- c <br /> Facility Contact: a � �3 -- <br /> ��,��.YZ��'i A- _ ►� g- sh._------ --- � I hone ��rte_ 2..- <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(i(Present during testing): — ---'--—__ ___----- ------_-_-- <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: `.a r __ .. <br /> [ecimicutn Conducting'I est ) <br /> -Credentials: —1;CSI-13 Licensed Contractor SWRCB Licensed Tank`Fester <br /> License Type: Gu y' License Number. -i 11, ���•.� �` (���� (� <br /> Manufacturer,rraining <br /> _—Manufacturer _ _— _—_ Cornponent(s) Date f'raininng Expires <br /> @ �yg4 <br /> I. SUMMARY OF TEST RESULTS <br /> Component Pass Fait Not Repairs Component Pass Fail Not Repairs <br /> Tested !lade <br /> 6 t tyt�Ee <br /> jr, <br /> bq <br /> } , <br /> este �te <br /> t{ £ 4 s <br /> __�Urac�rr� 7 <br /> ®s <br /> l <br /> i <br /> It hydro,;tali to"t),I k%as performed, describe what was clone with the water atter completion of tests: <br /> V "'r°.g>...� .1 _C .,-,3 > a" �. tF .{ C"!7 <br /> { _} �+ <br /> CERTIFICATION OF'rEctfNl('IAN RESPONSIBLE FOR cOwuuc,rlNG Mils,rEs,rlNG <br /> Tn the hevt o/nit•know/et/gea.th facts vtated in tltls tl cvwtttew are accurate aad in full compliance with legal requirements <br /> t�� „m- <br /> 1 �� <br /> � . C ©U P.,�4 I <br />