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®e i <br /> .,8"C33, ,nuary 2002 Pago_of _ <br /> Sec' r.dary Containment Testing Report Form <br /> - This arm is intendedfor use b %?&actorsperfbrmihgpetmio&c testing of USTsecondary cantainme the <br /> appropriate pages of thisform. )report results for all components tested The completedform.x�ritt and <br /> IV <br /> printouts from tests(if applica.4 ) should be provided to the facility owner/operator for submittal to al r I ag <br /> 1. FAC INFORMATION ED <br /> FAcility Name: L/F[1 Date of Testing: <br /> Facility Address: / �i n� mer ��'� <br /> -Facility _' (} 0 Phone: <br /> Date Local Agency Was Noti P 4 of Testing: ENVIRONMENTAL <br /> Narne of Local Agency Inspec jr('ifpresent during testing): . C RTMEN <br /> 2.. J.'ESTING CONTRACTOR INFORMATION <br /> Company Name: P e' i v7 7 e- <br /> 4 <br /> Technician Conducting Test:. ` _ <br /> 4 <br /> Credentials: VZST,R Lit aced Contractor D SWRCB Licensed Tank Tester <br /> License Type: - — License Number: <br /> t 9 <br /> Manufacturer jMjR& <br /> Manufacturer Component(s) Date Training aires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component . P Pas pail Not Repairs Component Pass Fail Not Repairs <br /> _ Tested blade I Tested Made <br /> L i _ 16,10 0 ❑ ❑ 0 ❑ 0 <br /> 'i5th: 0 0 ❑ ❑ ❑ 0 ❑ <br /> 0 ❑ 0 ❑. ❑ 0 0 ❑ <br /> T © O 0 ❑ ❑ ❑ Q ❑ <br /> -_ ❑ 0 ❑ 0 1. 0 ❑ 0 ❑ <br /> ❑ 0 Q ❑ ❑ ❑ 0' ❑ <br /> P ❑ o Q ❑ o ❑ 0 ❑ <br /> - 0 ❑ . ❑ O ❑.- o ❑ 0. . <br /> ❑ ❑ 0 D 0 0 ❑ ❑ <br /> If hydrostatic testing was performe ; scribe what was done with the water after completion of tests: <br /> C;E;RTWICATION I F TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowW, f ar stated' merit are accurate and in full compliance with legal requirements <br /> Technician's Sign r. _ Date- ? r <br /> T 'd <br /> 2*1E9 T 91.602 T s.1040elu00 AI a4 T 13 e26 :01 21 02 A®N <br />