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Flug 02 11 08:48a <br />i"2�t1-11 <br />SWRCB, January 2002 <br />Elit V Contactors 120946: 342 <br />p.2 <br />Page ` of <br />Secondary Containment Testing Rep lit Form <br />This form is intended for use by contractors performing periodic testing of UST secone a. ;containment systems. Use the <br />appropriate pages of thisform to report results for all components tested. The comple. a ,'�rnr, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfr--,r ubmittal to the local regulatory agency. <br />I- FA CII.ITV INFORMATION <br />Facility Name: ! ,12 ;5 Cf 0nT(V j Da <br />Facility Address: _ <br />Facility Contact: a a t o)b�QPhone: — <br />Date Local Agency Was Notified of Testing: - ( - j j Y `(- 237 - J L <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATI0.1i <br />Company Name: ELLIE. M w(0asg=ffi x nc-r - <br />Technician Conducting Test: LAME •VA RZZ <br />Credentials: CSLB Licensed Contractor 0 SWRCB Licensed Tar <br />License Type:. - License Number. i. <br />Manufacturer Training <br />Manufacturer Component(s) _ <br />fi <br />If hydrostatic testing was performed, describe what was done with the water after comp. e: `)a of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDM ACING THIS TESTING <br />To the best of my knowledge, thefacts stated in this document are accurate and in fu -7 nmpliance with legal requirements <br />Technician's <br />Date: <br />k <br />. <br />r <br />o© <br />.il <br />mom <br />. <br />no= <br />o000 <br />,. .., <br />mom <br />o <br />ago©o <br />■ <br />. <br />oo <br />cao©a <br />... <br />oam <br />o000 <br />. <br />If hydrostatic testing was performed, describe what was done with the water after comp. e: `)a of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDM ACING THIS TESTING <br />To the best of my knowledge, thefacts stated in this document are accurate and in fu -7 nmpliance with legal requirements <br />Technician's <br />Date: <br />k <br />