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b'' rl, <br />•SWR13 <br />I3, January 2002 V, CEO <br />Second'34 Containment Testin e�bff <br />This form isintended for use lycontractorspe ormingperodict ting <br />rf i es Of US T <br />i#j <br />appropriate pages of this form to report results for all components tested. The= --or <br />printouts from tests (if applicable), should be provided to the facility owner/operator f, -z sub;,' <br />L FACILITY INFORMATION <br />Facility Name: LL 4W W e�-r- <br />j -, L Date of <br />Facility Address: 3 3 () 4 1 -T �c ovi <br />A < N , lc-- �lc <br />4 <br />Facility Contact: 1-/1 ej <br />V - kA WN Phone: <br />I Date Local Agency Was Notified of Testing: f -z (()IOA <br />Name of Local Agency Inspector (ii(present during testing): <br />? Tr4QTYVfl 14111TrVn A d-4nrr4hTU Tlkrlmea , , <br />Page J- of 7 <br />61�5 <br />int systems. Use the <br />.41 test procedures, and <br />the local regulatory agency. <br />M� <br />Company Name. <br />Technician Conducting Test: �Pk­ " i ) <br />txt"( e'cc. <br />Credentials: 0 CSLB Licensed contractor <br />9,SWRCB Licensed Tank Tester <br />License Type: -74m 5 41-- <br />. <br />.,,.; <br />1 License Number: <br />s (02. -U 1' <br />Manufacturer Training <br />Manufacturer Component(s) Date Training ES:xpires <br />, 1 <br />1 <br />3. SUMMARYOF ESTRRSITI.T.9 <br />Component u�®® <br />ii • I� i i I 1 i:. I <br />�� <br />i <br />'.. � <br />, 1 <br />1 <br />W <br />��oo�■ <br />n000 <br />• <br />oo <br />r�000 <br />o® <br />000c� <br />31 <br />o00 <br />oo�so <br />�000 <br />0000 <br />It nydrostatic testing was performed, describe what was done with the water after completion of tests: <br />lcly fl, j C <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In this are accurate and in full compliance with legal requirements <br />Technician's Signatur <br />Date: Z. <br />