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Work Order: 2243450 <br /> Secondary Containment Testing Report Form <br /> Thisjorm is intendedfor use by contractary performing periodic tatting of UST secondary cuntainmentaysiems. Use the <br /> appropriate pager of this form to report resulis jos all components tested. 71he completed form,written tent procedures, and <br /> . prinioutsfrom trsts(if applicable),should beprovidedto thejacility owner/operatorfor submittal to the local regulaimy agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: r /� Date ofTesdng: Z5 / 06 <br /> Facility Address: alif>-WJ41 E F d4- <br /> Facility Contact Lf 7- Phone: o;W? 858 — / <br /> 1,4 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector f fprwad during tatting}; <br /> 2 TIESTIPIGCONT12ACroRINFORMATION- <br /> Com Name• rC1/ KdA 7457 <br /> Tedmician Conducting Test .a.A( i <br /> Credentials: O CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> Liceme Type:. License Number. p - <br /> Manufacturer Trarnin <br /> Manufacimer Como s Data Trainin 8x itrs . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repatn Net Rep*in <br /> Component Pass Xao Teed Mode Component p� Fall Toted Mad* <br /> X D o ❑ ❑ <br /> 9 e�7 ❑ ❑ D ❑ <br /> D ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> D D ❑ ❑ <br /> D ❑ ❑ ❑ <br /> ❑ ❑ ❑ D <br /> ❑ D ❑ ❑ <br /> ❑ D ❑ ❑ <br /> ❑ D ❑ ❑ <br /> ❑ ❑ ❑ o <br /> If hydrostatic testing was performed,describe what waa done with the water a&x compietian of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the belt 0/-my AnmvledgAthe acis stated in document are eecutale and in furl compliance wr <br /> with legal requemens <br /> t <br /> Technician's Signature- Date: .—-• <br /> Tanlmology-NDE 8900 Shoal Creek,Building 200 Austin,Texas 78757 <br />