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' 'Canfornia Se&dary Containmilt Tes ' eort FOrm <br /> TI.formas f.,use by contractors perfo tes*ng of UST"-Condmy cantaiswRenf systems Tfie cofom�, <br /> xvzffmtest pro ,and przwoarts from fm&(f ap ), be to ilte facility owner! r forsubmdW <br /> to the local regulatory <br /> agewy- <br /> :1. FACMUay RWORMATION <br /> Fad►xam: ` O q 3I— of T —i 3 <br /> F 34-7,5 Trw.,yf ct. 0 Tru, <br /> Fad► pfimk Too <br /> Daft Loral Agmmy Was Notified of Tes *: <br /> Name of Local Agency Inspector{¢p weart <br /> a. TFSDNG CONTRACTOR RWORMATION <br /> camopany Name: CGRS L <br /> ng PO B=.1489, Fort Collins CO 80522 <br /> Techmichux CooductiugTest g Kv%` k <br /> Credcolkls: 0 CSLB Tank Tester <br /> License I)q= I License Numben. O X— t 630 <br /> am MAN I <br /> ,azr s Dane <br /> vapor-less ift ZWffW Afode1309 Tester 41291W <br /> 3. SUAMARY OF TEST RFSMTS <br /> Not Rqktm Not Repaks <br /> Compomat, Pass MA Tested In <br /> t Pan Fail Tested Made <br /> rl i UE ❑ 11 (1 G `_ 51 ❑ 11 <br /> 8'1 r <br /> IR ❑ ❑ SDG 3_ j , CR ❑ ❑ ❑ <br /> pq ❑ ❑ ❑ UDC. 5-r, *I ❑ ❑ ❑ <br /> Is ❑ ❑ ❑ UDG rl`c� ❑ ❑ ❑ <br /> g'1 Yla,r,tfoleL P�' esii v� ❑ ❑ ❑ lal h v�' �i 11 S 13 ❑ ❑ ° <br /> A3 <br /> t1� �} l'..c�K Pn4 ❑ ® ❑ g7 Mcc a'yIf S IN ❑ ❑ ❑ <br /> 7} t f �Otr g' l Q, ® ❑ ❑ ❑ �� S� h k4F4 f` SLtiM ® ❑ ❑ ❑ <br /> nrvY <br /> �l <br /> PriyvwLjCVP6t ' ® ® ° ell F iI Ri Sex SIAPKI2 ❑ ❑ ❑ <br /> �'� M v►� 01 R� ❑ ❑ ❑ $7 Mc�nifoirtS 1 ❑ ❑ ❑ <br /> 0.2 M CS I LE t ® ° ° ° 87 s S eft ® ® ❑ <br /> X37 �r o vwPJ ° ❑ ❑ 7 ❑ <br /> Cr h v. S ii1 �3oX ® ❑ ❑ <br /> l P v rc, ❑ ❑ ® I S t l 'Q ❑ ❑ ❑ <br /> If hydrostatic testing was pea#anmed,d=ca=what was dome with the wafer after comwlrfton of tcsts- <br /> Water is frl mwd,processed andremoved from srte <br /> CERTMCATION OF TECWUCMN WMONSMLX FOR COMUCTMG TMB TESTING <br /> To the best of my knowledge,the fade stated but this document are accurate and irn full Compumsce 14&legal requhi m:ents <br /> .,per <br /> T 's Signature: k. Daft: 7" 16 <br /> ��7 <br />