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0 <br />SWRtS, January 2002 <br />11 <br />I to <br />Page =L— of -7 <br />This form is intended for use by contractors performing periodic testing of LIST recon dary containment systems. tfsethe <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 rhe facility ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: -Y - <br />.> 1 11,35 Date of Testing: <br />Facility Address: (,7,1 S_ <br />Facility Contact: % t L) <br />Phone: 0-0,1 3t --z - 1-7 q <br />Date Local Agency Was Notified of Testing: k I -az Lon <br />Name of Local Agency Inspector (ifpresent during testing): <br />Em <br />91IMM A RV 0V <br />��� a s w ..�®���.:" III �1� .. ��� <br />M M=m <br />"M M MOM" <br />MM - In � <br />III <br />II <br />o0 0 <br />®deo <br />If hydrostatic testing was perfonned, describe what was done with the water after completion of tests: <br />I/ <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />ro the best of my knowledge, thefacts stated in this document we accurate and Infull compliance with legal requirements <br />Technician's Signature: <br />LOOO/T000q� XVq 91:60 OTOVZO/LO <br />