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MAY -01-2003 09:15 RM DON EE PUMP CO. 209 x:57 9298 P-04 <br />W Kt_ 0, ta11aID Y LUV d <br />Secondary Containment Testing Report Farms . <br />77lis form is intended for use by contractors performing pert odic testing of UST secondaryccntoinntenf systems. Gael)?" <br />appropriate pager of thisfornt to report results jor all companents tested The completed form, written rest procedures, and <br />printouts from tests Cf applicable), should be provided to the facifiry mvner/operatar for sttbrtfttal to the loeul regulatory agency. <br />I VAe'lr ITV INRARkliTIAN <br />Facility Name: p D st S X SB b tt Date of Testing: — 47-o -6 <br />FaciGr• Address: A39 S, L *7' -- <br />Facilin• Contra: CZ_ Phon ,204 <br />pme Local Agency Was Notified of Testing : _ � _ <br />Name of Local Agency Inspector pfpresent during lestlngl: <br />•rrerisir. rnNTRAfTOR INFORMATION <br />Company Name: pf <br />Teclaliclan Conducing Test: ( <br />— -- --- <br />Credentials: ❑ CSLB Licensed Contractor <br />G SWRCB Licensed Tank Tester <br />License T}pe <br />Manuracurer <br />License Number: tf�.iSffiin �917 .0. <br />j+lanuraeturcrTruinin p <br />Com onent{sI ___-Date TnIning rxpircs <br />Fail <br />not <br />Tested <br />I Repairs <br />blade <br />71 <br />3 SUMINIARY OF TEST RESULTS <br />Cum anent Pass <br />P <br />Fail <br />I Not <br />Tested <br />R:patrs <br />Made <br />Component �r —Pass <br />Fail <br />not <br />Tested <br />I Repairs <br />blade <br />71 <br />- <br />- <br />r^ <br />❑ <br />-, <br />❑ <br />— <br />�^ <br />C <br />❑ <br />Dj <br />❑ <br />L <br />^^ <br />p <br />r <br />❑ <br />❑ <br />�� <br />❑ <br />❑ <br />G <br />_ C <br />❑ <br />❑ <br />❑ <br />G <br />_�_ <br />G <br />❑ <br />❑ <br />❑ <br />_ <br />❑ <br />0 <br />C <br />— <br />II' hcdrostatic testing was performed, describe what oils done with tltc water after completion ortests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I>, Nle ben ofnn huuuledyr, i'Ll <br />zefttas stared fit th' dactrment are accurale iced inf ul!Tcchnieian'sSigttature:Date: <br />