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01/22/2004 09:27 209-47885 Jan 21 04 05:10p RISHWAIN & RISS-" IN 20i§56.0214 T.-,---rRr--- 4r''. SWRCB, Sammy 2002 Secondary Contaii Ms form is tnrtended for we by contractors perform ing appropriate pages of tft form to report resules for aU c printouts franc testa (rf ,applicable), should be provided t I. FACrC rr PAGE 02/08 p.B Page 1- cr.. Testing Report Fo rin WWI UST secondary corrraitrtrient systems. urd the d. The C"Pleted form, written most procedures, and ,y16wne» Ieperator for submitlai to the local reguloron• agency TION Facility Name: :"k r'r�N 1« kk:t CAr Ll- Date Facility Address: s ht l:aoility Contact; I Phone: Dass Local Agency! Was Notified of Ten*: •� - Nene of Local Agency Inspe:Mr (rfpresemt daring tadmgi: 2. TESTING CONTRAC.'TM Wd RMATION iiw--"1= Company Namc: r� - a �- Psu Fall TMW Technician Conducting Test: t ej Credetttials: SLB Licensed Contractor 0 SWRCB Licensed Tank Tester _ ...—L Lice'tase Type; ManuEacturor Lice=Number. o,,,,- l)Eo'lC.G V�aA� c r'�rsietinp C ens c � d DateTraining Etc ire, A Tested 3. SUMMAYt'Y OF TRIST RFS'tTf .TS Component Psu Fall TMW N0z Rapairs Mads Component P:+ss Fail Not Eialjuirs i i Tested a�►e i1 p i A1C sulw ❑ {_1 ❑ S i r s S"I [J- -- t Ur 5 I ¢ivr e ' © Q' ❑ o I u N � I ' II ❑ - ^' © ❑ Q 0 [ i KWAui>2 ❑ ❑ o – ---rte . --� -- - 6 ❑ a a o ❑ _ c If hydrostatic testing wa_4 performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECNTIICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge', lite facts staled to this dOcamml are accurate and in full conpliance Will tegtal requirtttti etrtr Technician's 5ignanAre;