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DEC-31-2002 10 :36 AM DWEE PUMP CO. 2097 9398 P. 03 <br /> rPage of <br /> SWRCB. January 2002 <br /> Secondary Containment Testing Deport Forth <br /> rhir forno is furanded for use kv contractors performing periodic testing of UST secondary evntainntent+vstents. Umt 1hr <br /> appropriate pages of this forut to report results for all components tested The corupleted form, written rest procedures, and <br /> printouts from tests(if applicable),should be provided to the faclfity owner/operator for submittal to The local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facilit,'Name: td t I Date of Testing: I <br /> Facility Address; <br /> P <br /> Ricilir%'Contact: Phone, 2, y' -^ 1 <br /> pate Local Agency Was Nodfied of Testing: r4w <br /> Name of Local Agency Inspector(rf present during resting). <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company 1`ame: Gm - <br /> TechAician Conducting Test; <br /> Crcdenaals: SLR Licensed Contractor 7 SWRCB Licensed Tank Tester <br /> License T}-pe, License Number:J <br /> 1lanufacturer Train' <br /> manufacturer Cam oitcnt(s) Date Training Expires <br /> ires <br /> 3. 5UNIAIARY OF TEST RESULTS <br /> t1'at Repairs Nat Rep:tars <br /> Component P+sz Pait Vested Made Cumpuncnl Prtss Fail Tested l•lade <br /> C <br /> LI b+ V C <br /> ❑ ❑ G G ❑ Q G <br /> 0 ❑ ❑ ❑ ❑ ❑ C u <br /> ❑ ❑ C 0 ❑ ❑ G <br /> 0 ❑ + Q ❑' <br /> G ❑ C u Q G <br /> p �7 � L ❑ ' d G 0 <br /> I F In'drosladc testing was performed,describe w1im was done with the water after completion of tests: <br /> CERTIFICATION OFTI=CHNICIAN RESPONSIBLE rOR CONDUCTING THIS TESTING <br /> To the best of nit'knowled,e, t&fitcls stated in this docutneid tore accrtrate atrrl in fall compflunce nith legal requircnruntc <br /> 4 <br /> Techniclin's Signntt - Daae: <br />