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+ Dee 03 08 10: 08a Eli Iu Contractors Inc 208461 42 p. 2 <br /> SWRCJ3,J;inuan,2002 40 <br /> Secondary Containment Testing Report Form <br /> Thisfbrer7 iv intendcd.fitr u.,ve"by cvntractof:vprrfor•mingperiodic testing uf'UST.seconaczry contairrmefat.clrslems. Lvc the <br /> 11Pj7rGp1'701e pafres of dais fibrin to report results f)r 411 coh:purt4nls tested. 7ftr:conrplered form,written test per: <br /> rodurT,rnd <br /> printouts Prom tests(if oee <br /> nplicablc),should be prorid d to the facility oii nc}loperatrir for subntiiial to tine local res;ulatortP cr rent;% <br /> 1• FACILITY INFORMATION <br /> I'ikili Numc: <br /> .'.' ,6 A}ilC Uf Tcstinp,: •� '.ly/". <br /> raciiity Addres O <br /> �y x � <br /> S -- <br /> Facility Contact: /1/�� _ Phonc: <br /> Date Loc;d Agency IAra$Notified of Testing: <br /> Name OfLOc;%l Agency Inspector(ffprcvc»t during ievting): �— phi <br /> 2. TESTING CONTRACTOR Wri OI2MA TION <br /> Company Namc: <br /> "t"echnicianConductingTest <br /> Credentials: E CSLJ3.Licensed Contractor 0 SWRCB Licensed Tanlc Tcstci <br /> Licensc Type,, A.,f_'. Licensc Number. <br /> M:a n u fucta a rr r'I't'a i ea i m* <br /> Mannfacwrcr —� Com onent(s) _ Qatc TrHininn,Ex ires <br /> 3. SU1VC.11URY OF TEST RMULTS <br /> Coaatpunent Pass rail Not Repairs Not Repg;rs <br /> Tested Maaclr Component k'usti Tuel <br /> u..G�^ ��c�OC'�, 1.. ❑ ❑ Tested Maadr <br /> ij D <br /> ❑ ❑ ❑ ❑ <br /> d 0 D D 0 ❑ ❑ <br /> o ❑ 0 D O rJ !� ❑ <br /> 0 D ❑ O L1 ❑ ❑ C <br /> ❑ ❑ ❑ ❑ ❑ D ❑ ❑ <br /> C D 0 cc) 0 C <br /> If hydrostatic testing was performed,describe what was done with the Watcr after completion of tests: <br /> CERTT.FICA,TION OF TECHNICIAN kE,SPONSIIiU FOR CONDUCTING THIS TESTING <br /> 70[he be t Of err,,knowledge,t/te facts stated in this document are accurate and in full compliance wide legal requirements <br /> Technician's Signature: �� Date, <br />