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9255517888 Line 1 OQ•13;52 a.m. 04-19-2010 1 /1 <br />E DD <br />aft <br />6E T <br />ER HYA N IN.C. <br />. <br />PERM IT/SERVI'S ES <br />TESTING PROGRAM <br />AGENCY NOTIFICATION SHEET <br />i�L QYM 1r�' � 'l ��U w/o #:. LQO --S N Lo -7 <br />Notification Date: `r` <br />/ ® <br />Notification- For: <br />Requested Test Date: <br />Repairs <br />Initial Test <br />Facility Name: <br />Re -Test X <br />Site Name- <br />Facility #: 041 <br />Address: AP/7 ?j(% <br />1nWT— V - <br />City, State: <br />Agency Notified: 050V 0 <br />Method: <br />Contact Person: iC. <br />- <br />Verbal <br />Fax <br />Telephone: , r/ , ! <br />Fax #: ,7 38' - `7 tk �' t U� <br />E -Mail <br />Testing Scope (check all components that apply) <br />TP-201.4/ST-27 Back Pressure <br />Tank Monitor Cert/Bucket Test <br />TP-201.3/ST-30 PSI Decay <br />3-GPH Simulation <br />TP-201.6/ST-37 liquid Removal <br />TP -201.18 Static Torque <br />TP-201.3B/ST-38 PSI Decay AST <br />Drop Tube/Overfill TP=201.11) <br />TP-201.5/ST-39 Air/liquid <br />Secondary Containment <br />Repair Scope 6V�S <br />L�5 0 <br />Notification Contact:OWLW <br />-&-L,4-4a- <br />Telephone: 925-551-4777 <br />6747 Sierra Court, Suite J - Dublin, CA 94568 - (925) 551-7555 - Fax (925) 551-7888 <br />3140 Gold Camp Drive, Suite 170 - Rancho Cordova, CA 95670•• (916) 631-1300 - Fax (916) 631-1317 <br />-(AAA RI AArI'1 n...nil Q1-4 Q,,ifn RO . D..e..l....... e+n nenen . 1- ^'N mon on - r....-1—IN -inn nn.n <br />