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Work Order: 2279305 i <br /> ` S WRCB,January 2002 ® Page—of-- <br /> Secondary Containment Testing.Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form,written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY 1[NFORIYlATION <br /> Facility Name: d q T'Yo of Testing: p t £5 <br /> Facility Address: oe d.+�. l <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: ICC# <br /> Credentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,60,C21/D40 Iaz License Number: 300345 <br /> Manufacturer Trainin <br /> Manufacturer Co onent s Date Training E ices <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Pail Tested Repairs <br /> Component Pass Fail Tested Made <br /> tA be 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a a ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ Q <br /> D D D D ❑ ❑ D D <br /> ❑ ❑ ❑ ❑ D ❑ ❑ a <br /> a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ a ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 fit this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: J) t, :c' Date:_ 12 ^14, <br /> Tanknology Inc. 11000 N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />