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Dec 07 07 09: 08a Afforda Test (209) 744-0116 p. 2 <br /> S WRCB,January 2002 Mage-1—of <br /> Secondary Containment Testing Report Form! <br /> 7hls form!s intendedfur use by contractors performing perdndlc testing>Uf(/ST:CC Undary runtatrtment systernv. Usc the <br /> appropriate pages of this form to report resultv,for all Components testees The completedform,written test procedures, rand <br /> prinioutsfrom tests(f applicable),should he provided to the.fitcility owner/aperatorfor submittal to the local regulutury ulyency. <br /> 1. FACILITY INFORMATION <br /> [t~acili Naane:�t,.7U e.y�yc� Date ofTesting: 2— (( 06 <br /> Facility Address: ( '�- -t-v� �-p 1�t�(C�nwO9.eL . 9 -5-S <br /> Facility Contact: elle <br /> Date Local Agency Was 316fified ut'Testing: \1- 010 ` <br /> Name of Local Agency Inspector(if present during testing); <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Compan Name: 1 � eco. -tom <br /> 'I cchnician(:onducting'Cest: 44' CA,a, r vi <br /> Credentials: D CSLS Licensed dontractor WRCB LiuLmsc:d Tank Tester <br /> License Number. <br /> ManufaictuMr'Training <br /> Manufacturer Com ncnt(s� Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component ['ass Fait Not Repairs <br /> Te,Yted Made reacted Made <br /> %cont/ (.1 I-) ❑ U0 e 41,'S 1.e <br /> plc #z ca C.� ❑ u�� 7 ❑ u ❑ <br /> as a� #3 ❑ ❑ ❑ U 0 ❑ ❑ <br /> ee,. s-fe L 1 1.1 11 ❑ ❑ LI L.1 <br /> sef.arac�st r s`Z l 1 1 1 L.i ❑ ❑ El C1 <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> U Lt ❑ n fl ri 17 <br /> c i ..r, ��- ❑ ❑ l;1 ❑ ❑_ 0 —❑ <br /> r 3t�pC1::ix- <br /> 0 ❑ C! C.J i"1 n <br /> - r f a.- ❑ ❑ ❑ ❑ CI 1:.1 l:1 <br /> 2�7711-1--(T— <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 12 a r r�.d roc. .10 � ct/`+C -�G.� . <br /> C>ERT (CATION OFTECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowled a facts stated In this do nt are accurale and in full compliance with legal requlremenls <br /> Technician's Signa �-- a-+. ..a Datc. <br /> 2./11 /oG <br />