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0 <br />Secondary Containment 'Testing Report Form <br />This for;n is intended for use b}- Contractors per jorrrring periodic lesting of US7'secondmy containment systems. Use ,he <br />appropriate pages of this form lu report resuhs for all components tested. The completed jor-m, wrinen test procedures, :nd <br />printouts fi,(Jrra rests (ij appl icable.), should be provided to the f tcilio) owner/operator for submittal to rhe local r-e,grrlalorV aRencu. <br />FACILITY MORMATION <br />TESTING CONTRACTOR ENFORMATION <br />Component: Pass <br />�Tattic <br />Fail , Not Repairs <br />Tested_ Made <br />Notes: <br />Annular <br />----I <br />❑ ; El C <br />L.'. ❑ <br />_ <br />- —. <br />�; <br />it <br />Seconclary Pipe - _ ❑ <br />Turbine Sump; <br />UDC - ❑ <br />— <br />J <br />.� ❑ <br />❑ <br />❑ 0 <br />~J <br />Fill Sump - ❑ <br />Cl <br />❑ Ll <br />7 LM Sump- J <br />�.1 <br />u Ll <br />L <br />-I <br />Spill Bucket - _� <br />❑ <br />LJ I:. <br />- <br />_ <br />+ij <br />7 ❑ <br />�� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />USf'X� 17dZUt''ti P2'�l�C7l� 6A1 S eiL - - - _---- <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best uf'my knowledge, lire facts stated in this document tire accurate and in firll compliance ivitlt legal requirernena <br />Technician's <br />