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is Dem 12 02 10:09a <br />S WRCB, Jan uwy 2002 <br />Jay Carpenter <br />(510) 278-9137 <br />M. <br />Page I Of -7 <br />This form is intended for use by cordraclors performing periodic testing of UST secondary coreVWnent Systems- Use rhe <br />appropriate pages of rhisform to report ra dts fur all costpoMnts tested M wmpleted form, written test procedures, and <br />printof4sfrr. m tests (if applicable), .should be provided to lire faeiltty oev ierloperaw for submittal u) the local regulatory ag—Y- <br />•. 6Av88lAA A <br />hacilityNarne; Lkti..•rr.c.c� �r •r <br />I✓cf.o�✓a/ L.�d1 Date of Testing: tt-tg. <br />FacilityAddre= S'; f e 3av : /w e. v <br />Facility Contac".. Bev '-X. p {�S Phoatc: L L(ZZ <br />Date Local Agency Was Notified of Testing: <br />Name of Lt4W Agency Inspector Ci present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: D C fW Co ds fev c! h o r✓ <br />Tedmiciaj, Conducting Test: AN NN it O ' /Na —9 <br />Credentials KCSLB Licensed Contractor <br />o SWRCB Licensed Tank Test- <br />Lieense T -re: A — HA Z G 61— D L1O <br />Maad'aeRaaer'ITraiaeae <br />Ma�rifacturer Component(s) <br />License Number: 79 t 3 Sl <br />Date Training ires <br />IBM <br />CERTI)F{CATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING T"'S TESTING <br />To rhe be:tT e f my lrnowledge, the facts sttdad in thh dpruenent are aeettrate and in fair co a with legal regcrrrenaentt <br />Date: <br />Tc:chnicia,'s Siplatwre: _ — <br />SILd WdZT:BO ZOO2 TT •oaII SZT0+1£7+Sa6 : 'ON 3NOHd Ms : WOU <br />IBM <br />gin� <br />MM <br />EM <br />in <br />MEM <br />a r a • + <br /><• <br />CERTI)F{CATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING T"'S TESTING <br />To rhe be:tT e f my lrnowledge, the facts sttdad in thh dpruenent are aeettrate and in fair co a with legal regcrrrenaentt <br />Date: <br />Tc:chnicia,'s Siplatwre: _ — <br />SILd WdZT:BO ZOO2 TT •oaII SZT0+1£7+Sa6 : 'ON 3NOHd Ms : WOU <br />