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t <br /> SVM- CH,January 2002 Page I of I <br /> Secondary Containment Testing Report Form <br /> Yh�s form Ps iruetidedforuse by.contrac�ars perfosmi�tSP dlc test7ngof I ST seco»da c�orrta3xt»rerrtsystems Use the <br /> appropriate pages offt form to report results for all auVonerrts tweed The completed form,written les;proceduiw,and <br /> printouts f am tests(if tIppliciable),should Ire providedto tare far0y:vwaerloperatorfor submitral ao the local regulatory agency.. . <br /> 1'. FACILITY INFORMATION <br /> FF <br /> Name: .cc vi rv—o ' 1..'s e,nnri r e tJ t L Dais sof Testing, t p s <br /> Ad&m* e.3�o (- <br /> Contact: ev e C 0 r'G <br /> oc"Age ay was No3ised Testing: t D 0 S <br /> Name of Local;,M2 tPwtor rjjPresent during testingj; <br /> 2. TESTING C+QNTRA4CTOR INFUItMATION <br /> r13aAie0 1 a 'i <br /> dician Conducting Test; <br /> ntials: U CSLB 1:1censed �raator wRCB Licensed Tangy Toter <br /> cense'1ype:'Cww Iicense�+Iumber. U i 12nC <br /> n tf u rx5 In ng <br /> Manufactures Co nen s Date Treanor Ex ores <br /> 3. SUM ARY QF'TEST RESULTS <br /> Net Repairs <br /> Componfiat <br /> ent Pass Fail Texted Matte CompoSe" Pin 'Fall Vested tai <br /> $s <br /> T1 ]. ] <br /> ] ] ] <br /> L4 D <br /> O ] ] <br /> If hydrostatictestingwas performed,describe what was done with the water after completion of tests: <br /> �!'t'" [</ f i �r vie✓.0 C �pe�r r � e'vi ,. <br /> C=TMCATION OF TECEMCIAN RESBONSMU FOR CONDUCTING TJUS VESTING <br /> f ory g�th�e fad's rtatedrs°th�t aur- sra ��i�rce -Teg�aegentents ---- -- <br /> Technician's Signature: Date: <br />