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� a <br />Seeo�nd.az:y ContainmentTesting Report Form L� <br />This farm is livandadfor usa by eontraet�rsparforming pariodlc testing of US7'sacondory, containment .ryst i $ lla a 1802 07 <br />appropriate pages ofthts form to report results for all components tested rhe completed form, written teat procedures, and <br />printout.tfrom tests (ifapplicable}, shpul:l be provided to thefadi tyowner/operatorfor submittal to thif44 AW t 1 ruF�tj <br />Y FAr'TT.TTV TWWtIT?NfaTTf WL; .v'.i ! .,, rt,:Inp, <br />Facility Name:(3� ���1 Date ofTestin 2C�_0 <br />Facility Address: -r- EAQ-5hei3ail C(VICi.CA <br />Facility Contact, t— phone: ? %- 252-3--7&-7 <br />Date Local Agency Was NotiF ofTestuig <br />Name of Local Agency Inspector (?fpresent during test)ng): <br />Z, TES'ITNG CONTRACTOR INFORMATION. <br />Comp anyName:�ICH ENVIRONMENTALT <br />— — -- — -- -- <br />1" echnloian Conducting Test: <br />Credentials: aCSLB Licensed Contractor <br />0 SWRCl3 Licensed.Taak Tester <br />icenseType, 'C61:ID40 <br />jV,���facturer`I'rafrrSn¢ <br />Manufacturer <br />J. License Number: '809850 <br />' <br />Com orient s Date Trainin .E fres <br />INCON <br />INCON TS–STS <br />R;epaifs <br />Made <br />; <br />`l A tutV 0 . 0 0 _7 <br />01 <br />• .1).Ho <br />3. SUMMARY OFTEST RESUiTS:�',',-, ` <br />1 <br />Component 1PAS3kAidi Not Repairs <br />Tested Made Comp o. <br />Foss <br />]aAfi <br />Not <br />Tested <br />R;epaifs <br />Made <br />; <br />`l A tutV 0 . 0 0 _7 <br />01 <br />• .1).Ho <br />V $ e• ^ O 1 D 1 Q Pw WJl o10 <br />-D <br />O <br />c ?6,-o. a o <br />: o: <br />Q. <br />0 <br />i <br />L, 7 s W o D 1 0 <br />o <br />o <br />q I <br />ci :, <br />1,9P). D I D ❑ <br />0: <br />'p <br />O' <br />;fl <br />•0 00... <br />❑ <br />0..: <br />❑ <br />:D I <br />U XPQ I P( <br />le(krvN I I v o 0 J, o <br />. o. <br />o -1 <br />Q., <br />f <br />if hydrostatic testing was performed, describe what was dorsa with the water ager completion,oftests. <br />RECY E'AND_ E S <br />d: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE k'OR CONDUCTING THIS TESTING <br />To th e best of my knowledge, rite facts stated In flits document are accurate and In full compliance ,willt legal requirements <br />Tec hniciari'sSignatuie: v/- Date: 2_-?(,):2�z <br />