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Work Order: 2279784 <br /> S WRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This jarm is imrendedfw use by coraraclors perfarming periodic testing of US'Tsecaredmy cawroimmrnr syslems. Lae rhe <br /> appropriate pages of lhisform to report resully far all cc mpomemes rested 7'he completed form•wridem les!procedum.r•and <br /> priraaas from ttrts{ifapplk:able),shtsdd be provided to rhe frrilgv mrrrer/operypa•Jw sob�wfno!Jo rhr.Ja'al regrelarwy ogerry. <br /> 1. FACILITY INFORMATION <br /> Faeili Name: C D Date of Testing: 3 -0I-[ <br /> Facility Address: `lttlJAj, AGAK7'uuK- zi uG _ <br /> Facility Contact_ AIA,,A el- <br /> Dale Local Agency Was NoLfied of Testing: 11A <br /> Name of tarsal A gnwy Inspector(ifpresent during resift): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> C Name: &L. <br /> Technician Conducting Test: 6 <br /> Credentials: LB Licensed Comrad'Df -5 W RCB Licensed Tank Tester <br /> License Type: I e'6- Licellse Number• V4 1,6 <br /> Matlnferturer Tralain <br /> Manufacdmr COm en 5 Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Comyonetlt Yeas Fail rot Repairs Compoarfl Pass Fail Na Repairs <br /> Tested Made ]'eared Made <br /> n i J L ❑ �: <br /> pJW o n o _ n C n <br /> ? 56cd im- u J n F D J <br /> G 0 Q .1 L 7 0 <br /> r7xx N LJ 0 C J r J <br /> r r G il <br /> r3P 9C 7 ;J U C 7 D <br /> rs 5 G 0 0 1 L '] n <br /> t 7 L 0 it 3L <br /> 7 ❑ <br /> r I i LJ 0 :1 <br /> C ' 1 L. C I.i fl <br /> If hydro"ic testing was performed,describe whit was done with the water after rnrnpletion of tern: <br /> CERTIFICATION OF TECHNICIAN RESPONSISI.E FOR CONJJUCTING THIS TESTING <br /> To the best of my An0%jf0, t,Fhefam sauced in thir docsmmemt are aeveme amd in fall compalla ace with legal require—mb <br /> 1 <br /> Technicisifs Signan+rc- +s- .GQ+-,..a _ osia:. <br /> Tanknology Inc. 11000 N.MOPae Expressway,Suite 500,Austin,Texas 78759 <br />