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" <br /> S�MCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> ?l�aais form isinuoidedfor.u�e�, .�sas�acrorsperfvrnr�itgperu+d�ctest�irgof Z3STa�corularyc�ma�rinsentsystems. use ae <br /> appmpriate pages oftldsfrnm to report Muhsfor all raampOnem'tested 7be con7ldedforin xjam test procedures,and <br /> priruouts frons testi(if4pplicable),should he prvvided:to thefaciiity:owwyopmator fvr submittal to the local regulatory agency.. , <br /> L FACILITY INFORMATION <br /> a� 'Name: L-.ec W Y' L, v arvvi a r e Wa t Die Af'i`estin t p S <br /> Faeilzty Ad&=: +j e,0 (} r' � <br /> ,.ra t�e'� �� �i..d. TY�c- `�✓3"16 <br /> Conth e v er` •e r� e Phoae: <br /> Date t ocat Agway Wm*NotiSed Tesmg: p V S <br /> ?�Taaoe of i oval Agency LP T rfpresent dur3V testing); <br /> 2, 'I<ESTING CONTRACTOR INFORMATION n LEI <br /> N ,'M z Rv'. <br /> 'feclumicisuGbuduetangTest: �„�. �, �,v�. , <br /> • U CSLB Llceused tontmaor >$WRCBLIcmedTW&T=trr EM71FONNIEM ITA <br /> e s�:'C-cti►t fit._ -�S Y" LkenseNumber. O <br /> MamtiBctttrer Coffi nen s Date D#91eff px fires <br /> 3. SU Y QF TEST RESULTS <br /> N� �� <br /> ComPeneat I' Fa31 Tested Made Comsponent Piss Fsgi estod <br /> Mae <br /> tar✓ JK > > . <br /> s.2... <br /> C '`°"3c <br /> 0 <br /> b ' <br /> j <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Alf 4'L4r S i cuc�l �e.-�� <br /> Qrrr <br /> CERTJMCAnON OF TECEMCIAN RESFOI SWX FOR CONDUCTING T$tS T ESTTNG <br /> To tke brat ofsry Ss,tlsrc factac sluled sti'thls are accrnrrte and <br /> 4JWeOJwP&juv uiA legal regakenunts <br /> lof hWgian's Signature: . " <br /> Date: .111 0-5 <br />