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ACDEH,August 2003 Pap , of <br /> Secondary Containment Testing Report <br /> This form is inwnded f or use by insp"Hon sta$perfwming testing during installation of USTsecondary�oantainmenl systems. Use tine <br /> apprWiate pages of this form to report resultsfor all components tested The completed forms,written rest procedures,and prWcwti from tests <br /> (if applicable),shall be used in evaluating the installation of ne,v equipment and repairs to existing equipment. <br /> 1. FACTUM INFORMATION <br /> Fae ity game 1t�G�, bate of Testing: of '77 <br /> Facility Address: J 10 O S, �'L e•r n t~ . <br /> Facility Contact: j Q3 6t f 5 ,g C, _ Phone: <br /> Date T_ncai Agency Wa_g Notified of Tesring : ILA, j—) � <br /> Name of Local Agency Inspector(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION 7 <br /> Company U.S.T. Compliance'restin Inc. <br /> Technician Conducting Test: Tony Fontana/Bill McCarthy <br /> Credentials: x CSLB Licensed Contractor SWRCB Licensed Tank Test <br /> License Type:A Gen.Eng. #846288 License Number: -" <br /> Contractor's Manufacturer Trainine <br /> Manufacturer Ca i,ncnE(� 4_ Date Trainin�Expire's— <br /> In-con TS- STS 2-22-2018 <br /> YY <br /> 3. SUMMARY OF TEST RESULTS <br /> Pam Pae! <br /> Not Repairs [,: Not Repairs <br /> "ComponentTested Made Component Pass Fait Tested Made <br /> A�rwl c�' AK ❑ ❑ ❑ r I R ❑ ❑ ❑ <br /> (,►kA� ❑ ❑ ❑ ❑ ❑. ❑ ❑ <br /> `fit I"� ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑[LAD ❑ <br /> C <br /> LAO <br /> ti./ , y it ❑ E �-I... ❑ ❑ ❑ iJ <br /> if hydr(*tatic testing was Pcrfotmed,descnbe what was done with the water aftor completion of tests: <br /> Testing solution talon with us to use at next test <br /> inspector's Signature:_w Date: . `- l� <br />