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Dec 12 02 10:09a <br />SWRCB, January2002 <br />Jay Carpenter <br />(510) 278-9137 <br />Page L Of <br />Seconftry'Contaiument Testing Report Form <br />?ills forst is emended for use by cantrcctors Perfa rWAg periodte testmg of UST seea►dtry comWnmew systems. Use rhe <br />appropriate pages of thisform to report restdts fvr _11, -ow porrents tested ?Ree c ot►rpletcd forrrx written test procedures, and <br />Printowsft't -en renis (if appikabke), should be provided to thie farikity o rioperamr for submittal to due katal regalarory. agency. <br />1. FACIL!(TX iNFORMATIOl�i <br />racility Name; i•.4,«• r ,! wr c ,c G �' r t <br />/✓cf.o,✓af ! Date of Testing. u t - tg . <br />Facility Aa&e= S, --ie 3,v ro G v <br />Facility Contact: (fal Phonc: y qZZ <br />Date Loea! Agency Was Notified of Testing: <br />Narne of L pe al Agency lnspcetor WPM* during testing): <br />p.2 <br />' . CERTIFICATION OF TECHNICIAN RLWONSIBLE FOR CONDUCTING THIS TESTING <br />To Ike best r fury knowledge, the focal staled 1R fkh datums" are oeewate and in full co a wkk legal regatinemeab <br />.a.- Date:• � - t 8 - p t <br />Technicia l's Signature:: �'z/t -- �— <br />13/Ld WdzT:80 2002 TT '30G SZiO+T£trtS26 'ON 3NOHd M5 : Wodd <br />S <br />3. SUMMARY OF TEST RESULTS <br />- <br />Component <br />Not itp❑ <br />Cna®Ht <br />Pus Fad Tested Made <br />PassFad Not <br />Tested <br />Repa$ <br />Mad <br />ItFrv�c6Sv,�rd <br />Eudd <br />F3 D J <br />�09''' <br />❑ <br />D <br />3 P4 A'S <br />®uyNw/ <br />D <br />U <br />D7 <br />❑ <br />❑ <br />❑ <br />0i7a <br />c4ai�! <br />a <br />C, ;✓n O ❑ <br />n <br />❑ <br />D <br />tle✓lPa,f(. l for s <br />e p (3n D <br />❑ <br />O <br />U <br />D <br />D+esu=_/r�,v,✓u/oma S <br />eP 3r ❑ D O <br />❑ <br />O <br />O <br />D <br />D❑ D D <br />G O P -o o <br />C <br />O <br />❑ <br />D <br />-- <br />❑ ❑ <br />0 <br />D <br />D <br />❑ <br />_... <br />O U <br />u <br />EI <br />n ❑ <br />tno <br />❑❑ <br />o <br />u <br />D ❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ D <br />❑.❑ <br />❑ <br />0 <br />Uhydr�wtir. tasting was pafornacd, describe what was done with the waiter Ufta completion of tests: <br />WA_t_1 ( <br />OF 1A) 41J-e-,kTF- <br />' . CERTIFICATION OF TECHNICIAN RLWONSIBLE FOR CONDUCTING THIS TESTING <br />To Ike best r fury knowledge, the focal staled 1R fkh datums" are oeewate and in full co a wkk legal regatinemeab <br />.a.- Date:• � - t 8 - p t <br />Technicia l's Signature:: �'z/t -- �— <br />13/Ld WdzT:80 2002 TT '30G SZiO+T£trtS26 'ON 3NOHd M5 : Wodd <br />