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'MAP -24-2005 11:46 FROM:TRACY W K & AUTO S 12098325307 04683433 P.5 <br />3 WItCE. January 2002 Pap ai <br />Secondary Containment Testing Repon Form -- SpiH Buckets <br />This form is inrended1br a by cDniractorsperlarmtngperiodic testing af't� secondary cantainmertt syxten�; fisc rhe <br />appropmaw pages of this form to reAorr results for all components tested [ ne completed form. writren rest vmr-- ora% a= <br />printouts from tests (if aWncabie), should be provided to the facility Lumerioperatar for submittal ro the lm -,J, eeVlatory ageitc:1 <br />I. FACMITY INFORMATION <br />Facr7* Name: e i 2 e A Sr A I Date of T --sting Z_ 3— p <br />€aciy Address: Ci rat.: i v A mac <br />Facility Contact j Pone: <br />Date Leal Agency Was Notified of Testing: <br />Name of Local Agency Inspector rifpresent during testing): <br />? TESTING CONTRACTOR INFORMATION <br />Compauv Name: Champion Precision Testing, hw <br />Techaiciau Comhw ft Test: <br />Credmiais: X CSLB I. k=std Coma= C SWRCB 11ceimed Tmk Tester i <br />Liee> w Type. D40 LicenseNumber 804890 <br />1_ URufxtw ei `Kinins! <br />14L Component(s) Date T " ' F—,qktw <br />S Th B("Y OF TEST RESULTS <br />Component <br />Pass <br />Fail Not <br />Tested <br />Repnite <br />M9& <br />° ° <br />Cmast Prix <br />Fail <br />Not <br />Tested <br />Repairs <br />ma& <br />7 L /( <br />e, <br />0 0 <br />0 <br />0 <br />In <br />❑ <br />f 0 <br />4?- wn (Z <br />I 1 <br />0 ❑ <br />0 <br />1 <br />c <br />❑ <br />❑ <br />i.eTd <br />ff <br />❑ C <br />0 <br />❑ <br />C <br />0 <br />❑ <br />e ! t <br />I <br />n u <br />0 <br />❑❑ <br />! <br />❑ <br />D I 0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />C ❑ <br />❑ <br />0 <br />C <br />❑ <br />G <br />❑ ❑ <br />❑ <br />'❑ <br />0 <br />❑ <br />c <br />C) ❑ <br />0 <br />❑ <br />❑ <br />0 1Cl <br />D <br />C i <br />G <br />C <br />�:'I ❑ <br />❑ <br />c,cr <br />a <br />1 a <br />If hYdros'raric tmt ng was per6ormed descnbe what was done with the water after comaietwo of tests: <br />LWT" CA S 1"779 1 W,.47 - A%q <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the 1,ev of my lneawWge, the facxs&rae:i do ift& doc:ummt sae ueca mme and in fud c:ompiiawe with legal regi kmemm <br />1, =bmci=' S Signature: Date:1-7 - -0 S� <br />