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DEC -31-2002 10:36 RM DWEE PUMP CO. 2097 9398 P.03 <br />Page — of _ <br />SWRCB. January 2003 <br />Secondary Containment Testing Report Form <br />ilds jorn, is intended for use by contractors performing periodic testing of UST secondary containment .systems. U.ra the <br />onents tested The <br />form, written test <br />appropriate pages ojthisctable),report <br />ould be proovideall <br />d tot the facility o vner/operat r ftordsubmittal to the local regulatory agencv. <br />ocedures, and <br />prinmuLr front tests (if applicable), ' - <br />CA r11 1TV 1%tVnt)1%AATI(1N <br />f. <br />Facitiro Name: 1J 1 1R Date of Testing: I — <br />Facihty Address: e <br />Facilin• Contact: Phone: z, <br />Date Local Agency Was Notified of Testing: r4� <br />N:une of Local Agency Inspector (ifpresert! during f¢sging): <br />.-. 14r`Tr1D 1NCrlDAIA'r1nN <br />l LiJ <br />Not <br />PAYS Fuil Tested <br />Rvpnirs <br />Mad" <br />Com ancName: <br />Co <br />Foil <br />Technician Conducting Test: <br />Rel+atrs <br />MmIc <br />Credentials: d'CSLI3 Licensed Contractor <br />C SWRCB Licensed Tank Tester <br />License <br />License Number./ <br />Q ZI <br />Manufacturer Training <br />C <br />Manufacturer <br />y Cam oncnt(s) <br />Date Tmininq Es ircs <br />oris%111 A DV A4 Trc r r)rCItf TC <br />Component <br />Not <br />PAYS Fuil Tested <br />Rvpnirs <br />Mad" <br />camponent <br />Pass <br />Foil <br />runt <br />Tested <br />Rel+atrs <br />MmIc <br />C <br />❑ ❑ D <br />G <br />❑ <br />Cl <br />❑ <br />❑ D <br />C <br />❑ <br />❑ <br />C <br />G <br />❑ ❑ n <br />G <br />C <br />E. <br />C: <br />7 <br />u <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />G <br />G <br />❑ ❑ ❑ <br />I G <br />I <br />❑ <br />C <br />n <br />I i' hs drostatic testing ryas performed, describe %%hal lens done with the scoter after completion of tests: <br />�w <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />7b the hest ofntt' Anowledge, the JoL9s stated in this document are accurate and In full contpliunce udth legal requirenrenLr <br />a <br />An Rd <br />Technician's Sig,tntt < Date: <br />