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S'1A?-P,CB, fanuary 2002 <br />page <br />Secondary Containment Testing RepOfT Form <br />Atsjar)n is itmendkdjbr use by c;ontractor.vperjijrpTzingperft)4iic resting qf'(J,1J7'secorjdary coniainmentsystems. Cjsezhe <br />appropriaie pages qj'this jbrw to repojorresults .11br all components tested Ae cornpletedjbrm, written test procedures, and <br />printouts ftoin rests i if applicable), should be provided ro the facility uArneroperaiorfor submitial w die local regulatory agencv. <br />t. FACILITY fNFORIVLATION <br />Facility Name: L4,,, 1.�',aA Date of <br />Testing: <br />Facility Address: -2 A/ L-.); <br />Facial Contact: _54,rjdd <br />_e /— , I Phone: <br />Date Local Agency Was Notified of Testing <br />LName of Local Agency hispecwr (j]'present during resting): ZVI <br />2. TESTING CONTRACTOR INFORMATION <br />Tecbnician Conducting Test <br />Credentials: X CSLJ3 Licensed Confi-actor 0 SWRCB Licensed Tauk Test" <br />*7W, Will <br />MUM <br />M-Amidacturer Tr <br />Atnufacturer Conipone"t(s) Date Tfaining F-x*cs <br />Component <br />PasvJ <br />Fd I Not <br />Tes" <br />Repairs Component Pnss <br />Slade <br />Fad <br />Not <br />Tested <br />Repairs <br />'& -we <br />W7 <br />,_-y <br />I C', I <br />QeSp pr,.,A 14--L <br />L <br />1-71 <br />3 11 <br />11 [1 <br />Li <br />01 <br />ri <br />MU 0 <br />Cl <br />0 <br />L C, <br />0 <br />r7 <br />A <br />PJ <br />'d-1 <br />0 <br />E <br />7 <br />Lj <br />ff livdrostatic tasting was performed, describe what was done with ft water after completion of WSW <br />M <br />CERTIFICATION OF TECHNICIAN RESPONSIBLZ FOR CONOUCTING THIS TESTLNG <br />TU the bea ,f ?)q blondedge, thdfacz .stetted in this docantent are axurareand in full ,:ampfiaiw2 with l: gal requirements <br />Techiucian's -Simmnue:- z�f - Daie: <br />