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MAY-01-2003 09 : 15 AM DONL EE PUMP CO. 20937 9798 fir• 134 <br /> u� �G <br /> �w Ftl Q.J:illli:�r �uua <br /> Secondary Containment Testing Report Form <br /> This form is i►ttended for use kv contractors performing pert-odic testing of UST$eco7'tdary cc.►staf,►tttetrr:rvstenm (I've the <br /> approprfate pages ajthfsjarnt to report results for afl components tested The contpfeted,forrrt, 'Witter,test proceu'ures, nncf <br /> printouts from tests rf appticahie),ahaurd be provided to the focflity osvmgrfoperator for subrift(ai to Me local regulatoey agencv. <br /> I, FACILITY IN"FQRMATION _t - <br /> Fitcility Name: 0 D ,+! s !i<a"B b R Date of Test:,ng:�l exp <br /> F.scilicy Address: 479 . S, <br /> l=acilin'Contact: PhonOci — <br /> Date Laval Agency Was Notified of Testing: <br /> Name of Local Agency Inspector Cfpresent during testing): .... _ <br /> 2. TESTING CONTRACTOR INFORMATION ._.�...._..,.,.���.,._ <br /> Company Name: NAJ <br /> Technician Conducting Test:Jr. <br /> Credentials: n CSLB Licensed ContractorC �'V <br /> SRCE Licensed Tattk.Tcster <br /> License T3pc' Licetuc Number. �— <br /> • t�,,,'[�I'iltSurerTruittin�.� <br /> Manufacturer Gant oneni(s) Date TnAr in!3xr.'i.res <br /> 3. SWENI RY OF TEST RESULTS _ <br /> Not R::pyirs MIT Ilisn:drs <br /> Cumpuneni Pass Fail Testcci I'tads Cumpunvul Pass Fail 'listed a @Nadu !! <br /> 11 D <br /> 11 D J0 a <br /> a ❑ C E, <br /> Q C P <br /> 0 D G _. q C _ <br /> t - -- ❑ D D 2. �.. .__. ❑ <br /> G C, v C <br /> D [1 '1 ❑ ._.. ❑ a D ❑ <br /> D Lo <br /> II'h`drostatic testing was performed,descHbcwhm Nt-os done with 01C wuterniter compIC6011 Orte--,M <br /> CERTIFICATION OFTECH NIC IAN RESPONSIBLE rOR CONDUC71VG 711IS TESTING <br /> f 1!fill`1L""ft 4f 1773 17!)IF'iL'f�l�+N�t!e farts stared in th' durum v? are accurate,turd in Jird1 ct nli1f(r n--c ic'tth l ged req ttirvwre)r1+ <br /> Dt1te: <br /> Tcch�tici7n's 5lgt>r�lure: <br /> 4 <br />