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Aug -24 12 11:05a Elite IV Contactors 12094GIG342 P.9 <br />&WRCB, January 2002 <br />Page of <br />Aec Lxi"daky-&Iitainment Te. ing eelp ft Form <br />This form is intendedfor use by contractors performing periodic testing of UST seconzix - containment systems. Use the <br />appropriate Pages t?f1hisJorM to report r6sulls.for all components tested. The comple!?t farm, written lest procedures, and <br />printoutsfromtests (if applicable), should be provided to the facility owner/operviorfor. 4bmittal to the local regulatory agency. <br />I. FACILITY INFORMATTON <br />Facility Name: r- <br />D7t <br />Facility Address: <br />Facility C A - <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpreseni during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />I Company Nam. --t lift, I V. �Yyt <br />Technician Conducting Test: --V L <br />Credem:ia1!Ly CSLB Licensed Contractor D SWRCB Licensed Talk <br />License Type: <br />License Number <br />at <br />Manufacturer TraininE <br />3. SUNEWARY OF TEST <br />Component Pass Fail Not Repairs <br />Tested Made <br />RESULTS <br />compont U: <br />Pass Fail <br />este <br />air, <br />Made <br />U01,111 I El 0 <br />WW"i-L <br />0 <br />ID <br />[I c 11 11 <br />0 <br />0 0 D ElLl <br />0 <br />0 <br />Li <br />n <br />El <br />D <br />[1 <br />0 <br />0 D 0 0 0 <br />cl 11 0 0 <br />o <br />01 <br />El <br />0 <br />El E) Q D <br />t <br />0 <br />0 1 <br />El <br />0 0 <br />-P <br />D I <br />D <br />0 <br />-D_ <br />-EE <br />11 El 0 <br />If hydrostatic testing was performed, describe what was done with the water after completiai oftests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCII dG THIS TESTING <br />To the best of M., knowledge, the facts stated in this document are accurate and in full c(n 1,liance with legal requirements <br />Technician's Signature: Date: <br />❑D <br />