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SECONDARY CONTAINMENT TESTING -REPORT FORM <br />TESTING DATE: <br />JAN <br />0 2003 <br />LOWNER INFORMATION`k 1: <br />S -o5-1 LA <br />Name Address: Ph ne# <br />60vl-VQjv-e <br />(ylav(<e_j <br />&Jyuavd &-t <br />Contact: <br />2.FACILITY INFORMATION r700 <br />5')O - -73Z <br />Name: Address: Phone# <br />Contact: D', n Ct I Y-_iS we5� Ge4"Vipte <br />Tmq, 716 <br />3.LOCAL AGENCYTlFORMATIQN <br />Name: �EnvlrO. fkW h m 7'001hl Adress: Phone# Zo?- 466-3y2o <br />Contact: 5+oven -5hih Fax# <br />inspector present: -4 n +d4 by P40#f <br />F,4 yej la ve r Oxk- <br />4.TESTING CONTRACTOR INFORMATION <br />Name: JohAson 7-a're Vf I P� Licl PI S'Al 2 <br />Contact: AqAJyT0hkl50,M <br />-74- <br />Technician: Phone# <br />Number of tanks: 3 <br />Number of sumps tested <br />Number of piping runs_ <br />Number of UDC Boxes <br />C ONlEPONENT PASS FAIL COMMENTS <br />Annular Tank #2 Gasoline -89 <br />Annular TanlT3 <br /># I Gasoline -91 <br />Pi <br />Zing,Sumipfl Gasoline 91 <br />Piping Sump #2 Gasoline 89 <br />Piping Sump #3 Gasoline -87 <br />UDC # I <br />#1/2 <br />UDC_ #3DisD. ,#516 <br />LJDCW­___" _Disj).#7/8 <br />no -t We *0 <br />F-lbe,v4 vekck 5econAo ley cy5 4eb" <br />6e�- 4 ore Kc <br />Technician Signature�Date: <br />