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No-,0 14 12 12: 36p Elite IV Contactors 12094616342 p. 3 <br /> IV I.—W"%I ,. <br /> &NWRCB,January 2002 <br /> A Page <br /> d I I <br /> 04 <br /> mg <br /> ndar'y-t&&ai.ment Te * 4e ic -t Form <br /> This form is intended for use by contractors Performing periodic testing of UST second,u- ,ontainment systems Use the <br /> appropriate pages of1hisform to report results for all components tested The comple , <br /> wo urm, written test procedures,and <br /> printouts from tests(if applicahle),should be provided to the facility owner,`operatorfL-r Omittal 10 the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> U - <br /> Facility Name: (7) 1 7 Dat. of Testing: <br /> Facility Address. <br /> Facility Contact: rn4 <br /> Mo4a-r *V—I Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(present during testing): <br /> 2. TESTING CONTRACTOR INFO RMATION <br /> — <br /> Compny Name: <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor D SWRCB Licensed Ta.4 fester <br /> License.Type: License Number: <br /> 8ffi .f <br /> Manufacturer Traini-n2! <br /> Manufacturer Com ponent(s) Date Training Ex fres <br /> 3. SUMMARY OF TEST RESULTS <br /> Component <br /> Fail Not Repairs CPF.01 Not Repairs <br /> ---Pass Fail ass Tested Made Tested Made <br /> iyyf eca rd, 01 0 0 <br /> 11 - C 11 C! <br /> D 0 0 0 <br /> 0 D 0 0 0 0 0 11 <br /> 0 11 D 0 <br /> E) 1:1 D 0 <br /> ❑ 0 D 0 0 —0 , 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> Q 0 0 0 0 D .0— 0 <br /> D 0 0 0 <br /> 0 E. 0 01 <br /> • <br /> M hydrostatic testing was performed,describe what was done with the water aftcrcompletic oftests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR coNDucr %G THIS TESTING <br /> To the best of my knawledg <br /> ,F,4hef-w49-&qted in tare accurate and in full c.7t pliance with legal//requirements <br /> 3 10L-z" <br /> Technician's Signature- Date <br />