Laserfiche WebLink
S WRCB, January 2002 Z '� �_ I �% Page of <br />Secondary Containment Testi», p9, ^Form <br />This form is intended for use by contractors performing periodic testing .ST �g ontainment systems. Use the <br />appropriate pages of this form tore results for all components teste�} { �ritten test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owne /,�e`}'C�t�dNi� 7tal to the local regulatory agency. <br />1. FACILITY INFORMATION , , <br />Facility Name: r j [I Gt,� 0 V -p 0 Date of Testing:11 <br />—t. 6 r:. <br />Facility Address: C t C u ILr- 44-1-r- L <br />Facility Contact: - t)p, Phone: (x'0,0 313 _a < <br />Date Local Agency Was otifie f Testing: ITT, -3—F05 <br />Name of Local Agency Inspector (fpresent during testing): <br />2_ TF.fiTYNV rnNTR A rTnIDYMVnlDM A TTnw <br />3. SUMMARY OF TFNT RFNITT,'1'q--` � <br />Component Pass <br />p <br />Fail <br />Not <br />Tested <br />Repairs <br />Made Component <br />Pass <br />Fail <br />Not <br />Repairs <br />'nom t� c <br />El <br />❑ <br />❑ 1�. i C Yom- <br />El <br />Tested <br />Made <br />❑ <br />11 <br />El <br />El <br />El <br />El <br />0 <br />❑ <br />❑ <br />❑ tADCid, � ' �� <br />❑ <br />❑ <br />❑ <br />r ,11 J + , <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />h{ <br />it nyarostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in #ds document re accurate and in full compliance with legal requirements <br />I , <br />1A 1 <br />f <br />Technician's Signature:; ,� c_�..(� <br />-,-.�~-. ^,^.,`._ Date: <br />QT <br />