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SV' RCB,7umairy 2002 Page,._.._Of <br /> ecnnt •y Containment 'Vesting Report Form <br /> This'forirl is iut decd fUr use 6y cnr�lrpcivasperfunaaira�y periutlic testiar�r of cI51'seGUradrrry ri�rrtCatllaalerai SySfL�tlts. Clse i'he <br /> apprupric�te pores ,�''ehix jural,to repvrt;res � A�Gc!1rlppr�crll.S IPSP+; fie un�plelzd furry, wrftrcr�restPrauecl��res; uric! <br /> j" ` ui ��i� u e1 ur«r car subrrsirlal to IJie local re ulu��a1 +t�agency. <br /> pri"w"ufrom irsta,0f rapplivab u), shoo ,l ba p i � rr,rl�e a�jJ� P � S J S Y. <br /> 1. <br /> FU61lty <br /> Facility Addi ' �_ . <br /> Facilily Contact: _ _ _ Photo:: <br /> Dau:Local Agency Was Notified of Tesdug <br /> E!-i- AgrnCy I11spector(ifWresvni thiring testing): - <br /> _ 2. TESTING CONT17ACTOR rNFORMATTON_.- <br /> Coirt auy:.ftgawe: Champion;Precision Testing`,Inc; _ <br /> Tac llitiCiii l Cosiduaing,-rL,! . — C .i_ a <br /> Credeutiais: X CSLH Licensed Cunufactor ❑SWRCB Liceused Tang;.Taster <br /> Licepy Type: D-40 � Liceme Nusttber " <br /> �T .F:.1 'cYpR;-.c3C:..^: S R7CRgtR?.'A1'ARJ1'.Y'�i.rr�ff*;h;AC'Yf T r +.�,..l;e1R'e�" 0':�F7!'!}tr.rn.^,��ruC':vrJ""r..: <br /> lb't'aiw aetarer Ti-Ainina <br /> �:°��luttfaclurer Cot11�ot�sidls; 1)&le'1�ti►1ila Jrx ilea <br /> 3. SUMMA.n'Y OF Y"'QST RESULTS <br /> Cuu► buss it Not Repairs Colppunaut baba bail NW Repairs <br /> aui+tt � <br /> P T"tc I Mudie _ Tamil Mads <br /> �❑ _ ❑ E tJ f;1 <br /> 1] 17J <br /> I a _ , �� rl El LI C1 L:1 LJ u1. <br /> if hydrostatic testing;was perfiarmed,describe whal Was dobe M01 llie water after CIpietioA <br /> CELITIFICATION of TECfINICIAN R:CSPONSIBLIE FOR-CONDUCTING TWS 'j'ES'rrnG <br /> TO the best of my 1010)Vledbe,lhe, aaa aided In this dncararaelat are ac wraje and in fill!complialece wiM legal regjdrwnea h <br /> Daie: �/ C2 <br /> Techrieiwi's Signalure�f,� ._. -..._._ ......_,. <br /> ze/Ze 39td -nIH Nonan EZSECGCT99 cz :9t 800Z/90/ZZ <br />