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ar <br /> F E MI, ` 10 6 <br /> SWRCB,January 2002 Page of <br /> z LTH <br /> BMW <br /> Secondary ContainmmtV6�Aeport Form <br /> Thisform is irate far uw by contractorspetformmgpenodic testing of Wsecwdwy containment systems Use the <br /> apprWriate pages of thisform to report results for all components tested The completedfonnnen test procedures aW <br /> pr' fr tests(rfappli le),should be provded to thefacibly ownerloperatorfor submittal to the local regulatory agency <br /> 1. FACILITY <br /> Facility Name: Norm's 76 Date of T 1/5/06 <br /> Facility Address: 633 E. Victor Lodi CA MO <br /> F `lity Con Rob one: (209)367-1795 <br /> Date Agency Was Notified of Testing; <br /> Name of Local Agency Inspector(rf preduring to <br /> . <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: Hesketh Constuction <br /> Technician Conducting Test: ° o <br /> Credentials: CSLB Licensed Contractor Q SWRCB Licensed Tank Tester <br /> LicenseT Li se Number: <br /> Manufacturer T <br /> ManufacturerComponent(s Date 1gLcires <br /> JR; N!tLcq5 <br /> v <br /> c.- <br /> 3. SUMMARY OF TEST RESULTS <br /> Componwit Pass Fail Not Tested Co nt p F • Not Tested a <br /> de <br /> Premium i ' 1 <br /> 1us K!pm� EM U . U E3 Plus apor 0 E3 ❑ <br /> lar Piping 0 ❑ U U Regular FBI 0 U ❑ <br /> Premium r Vapor IM U I U ❑ <br /> Plus SumpU E3 U 13 <br /> Regular Sump U U E3 13 <br /> UDC 1-2 0 E3 U E3 U ❑ U 13 <br /> UIDC 5-6 <br /> UIDC 7- <br /> Premium <br /> Premium V or CM LI U <br /> If hydrostatic testmg was performed, 'be what was donethe water 9ter completion oft <br /> Placed acre and left o n site. <br /> CERTMCATIONSIBLE FOR CONDUCTMG TMS TESMG <br /> To Ike best of my knowledge, a and infug coW&nve wM kgal Muirements <br /> Technician's Si Date: <br />