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�µ <br /> 21 1VIRCB, Jamiary 2002 Wage <br /> Secy dary Containment Testing Report Form PHI B uckkzt <br /> ins form ss mxnaedjAbp arse by contractors performing perio&c testing i f 'ST seconclarJ contcgr r „ e rhe <br /> app=ropriate pages of`this form to mport results for ail components tester The completerifarm. ;vr'tten:est procedures, srrd <br /> pr,ntouts,;`�om tests(if appiicabie), should be pravided to the facility ownerioperator,`or submittal to the local megaton,agenc*i. <br /> I. FACMITY INFORMATION <br /> Facility Mame; ;--,e Date of Tom; lz9 -.Iel - <br /> Faadity A <br /> Fwilky Cant= � - <br /> Date Lacat Agency Was Notified.of Testing: <br /> Naute of Logi Agency Inspector(if premnr during testing): <br /> TESTING CONTRACTOR INFORMATION <br /> Compamy Name: ChanWion Precision.Testing, <br /> T g Tem: <br /> Czedenfiak X CMS Licensed Conwj= C S Tante Tester <br /> License Type: D-YW License . <br /> Mmufacftwer3'rsini <br /> ctfuer Co {st Date Training <br /> } <br /> 3, SUMWARY OF TIEST RESULTS <br /> V"Y <br /> Camppe I Piss Fed TN°t �. '� C nent ( Fad am <br /> TNS/ ! �✓� � Lei' ❑ l� � �.i � I..i <br /> 1� <br /> I L j i� i� ❑ �' �' <br /> u + L <br /> 0 07 'F L J <br /> E u L ❑ r1 v e <br /> ❑ ❑ ❑ ❑ ❑ •' L <br /> i Ej u ❑ �' <br /> If'=twrdros=c testing was perforated,describe what was done witft site water after camlefiaa of tests: <br /> CERTIFICATION OF TEC1Ii ICIAN RESPONSIBLE FOR CONDUCTING=TxSTING <br /> To the ziest of my e*e.the f ac:s.uteri:n dkis document rue accurazeand in fiW eo a with iegg ai requirements <br /> T�buiciau's Signature: y �;a='rsi�� �dte: '� � � <br />