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08/24/2004 09:51 9169277;44 CHAMPION PT INC PAGE 07 <br /> MM January 2002 <br /> Secondary Containment Testing Report Forra <br /> This,form is inrvxded_lb r use by conbucrors performing periodic testing of LtiST'eecnirdury containment systems, Use rhe <br /> aPPmpriare pages of thisjorm to report resalti far all camponenrs rester.. The completed farm. written test procedures, and <br /> pri17011t7frnm tests(if applicable), should be prrndded to the facility ownerioperator for submivai to the Aora1 regulatory agency <br /> 1. FACLLIT't INFORMATION <br /> Facility Natne: �p/7 raoc: ✓� �✓C� Date of Toadng: C <br /> Facility Address: <br /> sv 7 <br /> EELFacility Contact: /�lZDate La04 Agency W,ys NotifiedName of Local Agency inspector rf presentduring iesyng). '1/ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Coatpany Name: s an a _� <br /> Technician Conducting Test: S*e S t ca <br /> Ca adandhis: ❑CSLB Licensed Contracw ❑SRtPJM Ucensed Tank Tester <br /> License Type: <br /> License Number: <br /> Ivlanrdacturcr achsrer Trainiu2 <br /> Co nexus) Daw Tramin Expires <br /> 3. SUMMARY OF TEST.RESULTS <br /> Component Paso Fab Not Repair Caraponmt Pm Fail Not Repairs <br /> Tested Made 'Costed Made <br /> FJ"a V�.?0 {? clasT ❑ ❑ U ❑ ❑ ❑ ❑ <br /> q %Id/z ❑ G ❑ ❑ ❑ ❑ ❑ <br /> �ar'cL ! lac�<r£w J ❑ ❑ fl ❑ ❑ ❑ ❑ <br /> ❑ ❑ n ❑ ❑ ❑ ❑ <br /> ❑ n ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ a ❑ ❑ ❑ <br /> ❑ ❑ ❑ �� ❑ ❑ n ❑ <br /> ❑ 4 ❑ ❑ ❑ ❑ ❑ ❑ <br /> If trydrostatic testing was performed,describe what was done with.the water after compierion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOIL CONDUCTING TIM TESTING <br /> To the best ofmy Itrrawiedgp,thejaaN stated in this document are accurate and in <br /> fuU compliance wbth!dial requirements <br /> Txhnician's Simatwe:. 4�✓l {r <br /> -. Date., / <br />