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S"WRCB, January 2W2 PW of <br /> Secondary Containment Testing Report For — SpiH Buckets <br /> This form is intended for use by contractors performing periodic testing of IST secondary conuwnment sysrems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form, written test proceclttre% and <br /> printouts,from tests(if applicable), should he provided to the facility ow nerioperator for submittal to the local regulator, agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: bate af Testinr- <br /> Facility Ad&=& e e r/ Ti9c <br /> F O <br /> Date Local Agency Was Notified of T <br /> Name of Local Agency Inspxtor r1ft during testing): <br /> Z. TFSTING CONTRACTOR INFORMATION <br /> Company Name: ChampionPrecisionT Inc. <br /> Technician- Test <br /> C X CSLB Licensexi Com=ctor 0 S Tank Tester <br /> License Type: D40 License t 804M <br /> maluffacturer <br /> T <br /> Nianiffactiffer Co neut(s) Date Expires <br /> 3. S Y OF TESD"RESULTS <br /> Component Puss Fad Ifet Repairs t <br /> Repairs <br /> T C ent Pass Fad Tft <br /> LJ, �• " 9- ❑ ❑ ❑ ❑ L ❑ ❑ <br /> ❑ 2, ❑ J 0 ❑ <br /> M <br /> ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 0 ❑ 0 ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0' <br /> ❑ ❑ 0 ❑ ; ❑ <br /> If hydrostatic testing was performed,desenbe what was done with the water after complefton of tests: <br /> CER CATION OF TEC13MCIM RESPONSMLE FOR CONDUCTING THIS TESTING <br /> To the Itet of my bun4edge,the fads sWed in this document are accurate and in full evnlwnce wdh legal regttaremertts <br /> Tec3tnician's Si Bate: <br />