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ACDEH, August 2003 Page of <br />Secondary Contaiinmtent installation Testing Report <br />This form is intended for use by inspection staff performing tasting during installation of UST secondary containment systems. Use the <br />appropriate pages Of this form to report results for all components tei . ted The completed forms, written test procedures, and printouts from tests <br />(if applicable), shall be used in evaluating the installation of new equipment and repairs to existing equipment. <br />1. FACILITY INFORMATION <br />F -IM i <br />C,,,#7,YVV,-t,4-CT.OR, INFORMATION <br />Company U.S.T. Co i,6 <br />CSLT3 Licensed Contractor <br />Tj_ccn�e_Ty�;: A Gen. Eng. #846288 ---------------- <br />CoW <br />_-Manufacturer <br />o1 TS- STS <br />x SWRCB Licensed Tank Tester <br />FLTic�,eas�i4iiitber-.92-1153191-1151 <br />an <br />nent(s) Date T <br />6-6 <br />T at wss �done with the water after completion of Em <br />Inspector's <br />2T/2'd 22t7289t7: 01 <br />Date. -7 —1 bl�� <br />9NI1S31,dw03,1sn:w0aj 82:13T S002-8T--inf <br />�� <br />array <br />r <br />ra�r� <br />c�a <br />T at wss �done with the water after completion of Em <br />Inspector's <br />2T/2'd 22t7289t7: 01 <br />Date. -7 —1 bl�� <br />9NI1S31,dw03,1sn:w0aj 82:13T S002-8T--inf <br />