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Feb 05 03 02:29p E1^+on Hathaway (531') 755-1950 p.2 <br />SWRCB, MAY 2002 Page i of <br />Secondary Containment Testing Report Form -- FINAL DRAFT <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br />pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />� � A carr rrffV%7 YAT'1"d",77 i► 9 Art'Y"XT <br />X. A A AIL IN JL <br />Facility Name: <br />Date of Testing: --2-03 <br />Facility Address: <br />/ -,4c, <br />Facility Contact: <br />J� �,�� <br />Phone: <br />Date Local Agency Was Notified of Testing: _22_ �^ <br />Name of Local Agency <br />inspector (if present during testing): <br />A �vm�T T7►7T /1T l►T A''l�il11�T <br />G. IJr-J31, it 17 %—"I t li vAv A1NA'VA\1♦u �11VA� <br />Company Name: ACCT -TEST <br />Technician Conducting Test: ELDON HATHAWAY <br />Credentials: <br />�] CSLB Licensed Contractor [SWRCB Licensed Tank Tester <br />License 1ypc: <br />Manufacturer <br />License Number: 1002 <br />Manufacture Training <br />Componentfs) Date Trainine Expires <br />v-♦ mrtnm 71T07 TV TG' <br />If hydrostatic testing was performed, describe what was done with Wwaier anter comN uu1i ., <br />WATER WAS PROCESSED <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and hn full compliance with legal requirements. <br />r•��o <br />c�aior�! <br />'��■� <br />o©coo <br />as®v <br />�©r•�o: <br />c•�noc� <br />r�■��r�r�Q�PC <br />c�cayr� <br />If hydrostatic testing was performed, describe what was done with Wwaier anter comN uu1i ., <br />WATER WAS PROCESSED <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and hn full compliance with legal requirements. <br />