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From DIALYSIS NORTH to 19494501177at 10 ".8/2002 2 : 16 PM <br /> 00� <br /> ZiW KC K January 2002 <br /> P�Lge of� <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> ThrsJ�,rril it inleruled for use by euRfracrovs perfprMetnBlst►icxlic lasting ajt15T srsdary cn�erarnrorerrf sysdems. Use rhe <br /> aper ppriere p ,.es of tlrrs jorrrr rn rrpr�rr results for ell cnr,yxme+rts tested. The ramplered farm, %,phren team prvcrdures,and <br /> prinrouis from rests(if upplie able),v"Id br provided m rhe facility arwrm1oprmtorforswbrrrittal ro the,ItX !regwialory agrnry. <br /> I. FACILITY INFORMATION <br /> Facility Name_ gdo sii (0100 L7ate ufTcsting: /Q 62 <br /> Facility Address: 7- S775 So. T_ on1 Pots- 4Cq, <br /> Fxikity Contact: Nl t_� Phone: ZC> _ T77y <br /> Dale Local Agency Was Notified of Testing- q_Z O <br /> Narnc of Local Agency Ingpeewr(if present during resrirg): <br /> 2. TESTING CONTRACTOR UVFpRMATIDN <br /> Company Name: 'A L 5 15 JIJ p RTI4 <br /> Technician Conducting Test eN <br /> Credentials: CCSL13 Licensed Contractor IISWRCB Licensed Tank Tester <br /> licence Tyre: License Number g /Z--. <br /> Maeuratturer Trainin <br /> ManufaClurtr Com cnt s Date Trainin Ex ices <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pees Feil �O1 "n Coopocest Pass Fan Nat R m&i <br /> Teatrd Made Tested Medk <br /> k LAA- ■ D c 1 t ■ ❑ u <br /> K � uw, ■ ["i G is Sar.w. 3 • Li ❑ ❑ <br /> D ❑ 'J L.I 0 G S k ti, s 1 ❑ C 1i <br /> f ■ G ❑ ❑ Ld O e- 1! -7 ■ ❑ C D <br /> r4P'W1 J FILL 5UMIPf* • C] LJ G <br /> PrAO' 1 ❑ D ❑ 't CC t. 11 3 ■ U ❑ ❑ <br /> P. 144yt*5 ■ U G ❑ E,t{ t ■ C 7 u <br /> P1,0"A4 +i 1 ■ Q ❑ G F14Z t • Ll ❑ ❑ <br /> 1 «!� SL,.►.P dkZ ■ ❑ IJ ❑ Pr[c S cc .� ■ ❑ U LI <br /> If hydrostatic testing wag performod,dc9cribc what was doov with thc.water after cotnplation of fi!zm: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> Ta eke best of my knoxiedge,rhe facts aarad iw/llels documewt are mccunwe"d ie fish curaplsswar rdrlr legal l+C4rrirrntents <br /> Technician's Signature:—/�z _ pati:: l r rV Vz <br /> r <br /> r ` 1 IV <br />