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U ULL--3\0 LL=U V LLL'_&' <br /> SwRCB,January 2002 NOV 1 g 2007L Page J- of 2-- <br /> S.Ie.L.ndary CO�ntailimently" � Drrt Form <br /> Thisform is intended or use b contractors erformingperiodic teslin Rjol�jrlS7'eco"Iary containment systems, Use the <br /> f f Y P g1 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facilit�r-oivner/operator for submittal to the local regulatory agency, <br /> L. FACILITY INFORMATION <br /> Facility Name: M 4,r i 3b-211 Date of Testing: L t V d <br /> Facility Address: (o o Cr-L" ,S Z0 <br /> Facility Contact: 44 Lj Phone: �.,P S- �j� a r ', <br /> Date Local Agency Was Notified of Testing : (( drZ <br /> Name of Local Agency Inspector(fpresent during testing): 2 40 kAA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:—P— C'm,,, �L ck,,c-e- e rv` <br /> Technician Conducting Test ( yr F , U v`C.k1v\ <br /> Credentials: 0 CSLB License Contractor WRCB.Licensed Tank Tester <br /> License Typ . Un.aU- T e S 4,r_'e• License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Daae Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Y 3 ❑ ❑ El ❑ ❑ ❑ ❑ <br /> c �v<Ci IfZ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑. ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a ❑ a ❑ ❑ . ❑ ❑ ❑ <br /> 0 0 0 0 ❑ ❑ ❑ ❑ <br /> 0 0 0 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑. ❑ ❑ ❑ <br /> If hydrostatic testing was performed,,describe what was done with the water after completion of tests: <br /> Yet - `411P r s ,•�g. a ptai: O tt c�r <br /> A' <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To-the best of my knowledge, the facts stated Its fills document are accurate and In full compliance with legal requirements <br /> Date: I <br /> Technician's Signature. .�ti- <br />