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Work Order: 2279305 <br /> SWRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This form is Intended for use by conh-actors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form,written test procedures,and <br /> printouts from tests(tf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: c e..,w-. Date of Testing*. t a 2. -ica <br /> Facility Address: <br /> Facility Contact: hone: <br /> Date Local Agency Was Notified of Testing: <br /> Nance of Local Agency Inspector Cf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: zV eK * a " ICC# 3 <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,cl0,C21/D40 Haz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer ComDon-1-1 Date Training Ex fres <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Rers Not Repairs <br /> Component Pass Fail paiTested Made Component Pass Fail Tested Made <br /> -7 o ❑ ❑ ❑ ❑ o <br /> ❑ ❑ 0 0 0 ❑ ❑ ❑ <br /> D ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ o ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ D ❑ 0 ❑ Q Q <br /> ❑ o Q ❑ D ❑ o ❑ <br /> D ❑ Q ❑ ❑ ❑ D o <br /> ❑ ❑ ❑ ❑ ❑ ❑ Q ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and infill compliance with legal requirements <br /> Technician's Signature: <br /> � �. --- <br /> Date: /e% Z <br /> r� <br /> Tanknology Inc. 11000 N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />