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. i • <br /> a`rRCB. .TamL-wr 2002 owe of <br /> Selma d v Con nt Westin; Report Forte. - Sp B-de gets <br /> ":"zi.�form s LntendedJor:rse by contractors nerfnrmrng pe�^ivdic yestinb of�SI'.secnn�ri cOntirinmenr systkns;;. U;�,e thc� <br /> ::apprapriate pages of lhis form to report res5rits for all components tested ?"ne ccmnleleeci farm, written test promadurov, unci <br /> printouts"rom tests(if appiiccable), :should ae provided to?he facility ownerionerntor;far autanurtai to he loc d reguiatopy ggenc:;. <br /> 1. FACILITY INFORKAnON <br /> Facility Name: o Bate of Testing: r� <br /> Facility A .0 �^ <br /> ,any eJ <br /> Daft Leal Agenzy Was OMotified of Testing: <br /> Name of Local agency Inspector Cif'present dining testing): <br /> Z. TESTING CONTRACTOR INFOWMAnON <br /> Compaury Naive: champion Pression T Inc. <br /> Technician Condmaing Test <br /> Cs X CSLB Licensed Contratinr G SWRCB Lu=sed Tanis Tester <br /> License Type: D-40 License Number <br /> Manufactmr <br /> Com (s> Late 12!2jn5F=PireS <br /> I SUMWARY OF TEST RESULTS <br /> Component i Asa Fad�T I �s Cumponueat ?W�gad Not <br /> I <br /> :ie C ❑ f r j t❑ ❑ ! <br /> ,,i i! ❑ ❑ ❑ l ii <br /> �� ✓f Lei o g 11, <br /> ❑ <br /> v J ❑ ❑ I <br /> ❑ n ;; ❑ n <br /> ❑ ❑ ❑ ❑ ❑ 1.] <br /> IP ❑, ❑ 11 U ❑ ❑ El J u <br /> ❑ ❑ ❑ ❑ , <br /> ❑ f <br /> E <br /> If hydmstatic testing was performed,describe what was done witk the water ager campletion of tests: <br /> CER=lCAn0N OF TECHNICI&M RESPONSIBLE FOR CONDUCTING THIS T-+SANG <br /> To the jest of MY Anowiedf r the fate's"ed_n lkis rinrument:are ace—srate and in ftatl�nn<pluneev svit/a c;sl reraurremenas <br /> "'.°=i1uic;.an's sioaattire: ._ rater ��_ <br />