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NOU-14-2006 10:53 From: — To;2094683433 P.2/6 <br /> S WItC$,January 2002 �Q <br /> Secondary l Pie —of- <br /> Containment Testing R port Form <br /> This jornt is rm^ded jot are by ccmracrws performing perindlr.ferrfra$ojUS'Tsecortd <br /> approprI pages oftAi•.rJ6r'm Io report resttllt for a//canpanpRlS sled The PIaC eonaimne"I*,Ismr. Use the <br /> printoatr ream lestt(�applicalilef,shoald(re provided to the jaciliry owner/ �l a -�' sWWW ts'u rocs <br /> op¢ralwjar.rabmivaltorhelaca/r one <br /> I. FACRiTYINFORMATION ¢galafory 48snry, <br /> Facility Name; r <br /> Facility Address: - .4 _ Uate ofTesLin Facility Conrad: <br /> Date Local AAM Was N fled of x: Phone: <br /> Name of Local Agency Inspector(Ipr __. - <br /> rasra daring testlnp,J: - - <br /> Comp Name: 2. TESTTNGCONTRACTORINFORMATION <br /> ion Precision Testm- <br /> Technician Coodmoting Test: •- ... <br /> Credentials: Service Te <br /> chnician# <br /> X CSL$Licensed Conlmetorr gWRCLicensed Tank Tester <br /> Lieensc Type; 0-40 ❑ H <br /> License Number. 848150 -' <br /> Mmtufacttacr -� � a <br /> ComporLent(s <br /> ._ - ..L 2L - ._. 17a1e Trawl w$a 'to <br /> I SUMMARY OF TEST RESULTS <br /> Component Pass Fail 'rNot Repairs <br /> ested Made Pat Com ent Pare Fsu p Not Reairs <br /> '1'eclea Mata <br /> ._.... 0 ❑ L C ❑ ❑ F) <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ _.. D ❑ ❑ r� <br /> k ❑ HP CI_ ❑ <br /> D p i_I <br /> IF u e u u <br /> r C f ❑ ❑ ❑ ❑ ❑ ❑ u <br /> �' -- e u ❑ a ❑ ❑ ❑ a <br /> a 6 U 1W El 1.1 ❑ ❑ ❑ ❑ r <br /> �� U i ❑ C -- ❑ 1-1 _ ❑ ❑ <br /> hi ❑ n ❑ o D ❑ ❑ <br /> if hvdromfie teeing was performed,dtscribc what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR.CONDUCTING THi3 TE9TlNG <br /> ?b the hest of nsp knowledge,rhheee fica glared in avis docrrme"I are accurate and in fyll evMpllaeee with legal r/equi emeatr <br /> 'technician's Signature:-'" �� Dater <br /> I -d SbE/..L.689T6 uo}snLl L{yiaq WI I = IT 90 111 now <br /> _- ------ _... •• "w-, eGt - I L `91J L 1 nOtd <br />