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RECEIVED Jun 24 11 07:OGa Elito IV Contactors 12094 34 JUN 2 4 2011 sWRCB, January 2002 7� EWR0NMENTALfW&'f .1 Secondary Containment Testing Rerx i -t FoRMITISERVICES This form is intended for use by contractors performing periodic testing of UST seconad7r :ontainment systems. Use the appropriate pages of this form to report results for all components tested The complet. �6 !irm, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator fo -, i bmittal to the local regulatory agency. Facility Name: —•-- S (! Dut, ojTesfing: s f aFacility Address: I!=Facility Contact: U{Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (ifpresent during testing): TC�- 2. TESTING CONTRACTOR INFORMATION Company Name: l " Technician Conducting Test —Mato – Credentials: 0 CSLB Licensed Contractor Q SWRCB Licensed Tank License Type:. EF – LicenseNumber:.. Manufacturer Training 3. SUMMARY OF TEST RESULTS _ Not Re airs Component Pass Fail lasted Made Component . Pass Fail Not Repairs � El ❑ ❑ Tested Made — ❑. ❑ ❑ a ❑ ❑ d ❑ ❑ ❑ ❑ ` ❑ ❑ o _.. ❑ ❑ a ❑ ❑ ❑ ❑ D ❑ ❑. ❑ ❑ ❑ ❑ ❑ ❑ - ❑ ❑ ❑ a ❑ ❑ D ❑ ❑ ❑ ❑ T ❑ ❑ D.. ❑ 0 ❑ ❑ ❑ ❑. ❑. .0 D _....❑.. ❑ ❑. ❑ El 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completioc c .tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCT-Va PHIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full corm, 71 c nce with legal requirements Technician's Signatu