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SV.YRCB,January 2002 Pal;o of <br /> Secondary Containment Testing Report zoos <br /> This form is/ntenl'ed for use by contractors performing pertodtc testing of=. Use the <br /> appropriate pages of this form to report results for all component's tested The completed f. <br /> printouts from tests WaWlcable), should be.provided to the facility owner/operator for submittal to the cedures, and <br /> FACILTl'� local regulate <br /> regulatory a gen <br /> cy, <br /> . 1. . 7NF0 ON. <br /> Pacffi Name:TA.e.� 1 c. 1 <br /> pac�ty Ams, Date of Testn ; ,� <br /> �, �5�-ta <br /> Facility Contact F ; ® <br /> Phone: 2a�' r..�7 <br /> .Date Local Agency Was Notified cif Testing <br /> Name of Local Agency Imnector((f Present during testing; <br /> Z, TESTING cONTRACTOR INFORMATION <br /> Coni an Nam . I �„ S <br /> Technician Conducting Test: pt-k 0�wit <br /> C edehti is;'?' 0 CsL Licens Contractor' <br /> to WRC8 LM <br /> icensed Tank TesterLicenseType: n cense <br /> Number: <br /> ManufaQtwer D'a, cJU er,Trafee,nine <br /> Com otien s pate Z'rainin E fres <br /> 3.. .$. . . Y OF TEST 1 <br /> ESU>C,TS <br /> Component Pass Fall Not. Repairs <br /> Tested Made Cotnponent Pass Fadl Not Repai <br /> stirs <br /> eaw ew et 4/G p O l7 Tasted s e <br /> at lr etJA' p . Q D ❑ O Q <br /> .L ❑ ❑ ❑ 0 D 0 O <br /> r _ �.: ❑ p o D .. .D. D .0 <br /> ,e e-0t1vt D D. . 0 p <br /> O ® D . • � O D D 0 <br /> w <br /> r. (� 0 ® O <br /> D ❑ . 0 D 0 ❑, q <br /> O .D ® O GT O �7. <br /> 0 - -Q O ' O D O D 0. <br /> ❑ .. p Cl D O O D <br /> If hydrostatic testing waS porformod,'dirdcribe what was done with.ttic water after completion of tests: <br /> tai a e ' <br /> C$RTInCATION OV TECHNICIAN RESPONSIBLE FOIL CONDUCTING Ttils TESTING <br /> To the Gest o, my knawle�/ge,the facts stated In this ument are accurate and NMI compliance with:leg requlrements <br /> t. v <br /> Techuiclan's-SiSfijturc: <br /> Date. <br />