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Work Order: 2279307 <br /> t <br /> SWRCB,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 this form to report results for all components tested The completed form,written test procedures,and <br /> printouts from tests(if applicable),should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATTON <br /> Facility Name: G'' Date of Testing: 2 t 4 <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2. TFSTI NG CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: ICC# <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,c10,C21/D40 Haz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Cornvonent(.1 Date Training Expires <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> Component Pass Favi Tested Not Repairs <br /> Component Pass Fail Tested Made <br /> tU %' -a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ D <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ D <br /> D 0 ❑ ❑ ❑ 0 D ❑ <br /> ❑ 0 0 ❑ ❑ ❑ 0 ❑ <br /> a o ❑ ❑ ❑ ❑ ❑ ❑' <br /> ❑ ❑ 0 ❑ ❑ ❑ 0 D <br /> ❑ ❑ ❑ ❑ ❑ ❑ D ❑ <br /> ❑ ❑ ❑ ❑ a ❑ ❑ ❑ <br /> ❑ D 0 ❑ ❑ 0 ❑ ❑ <br /> ❑ ❑ [—EF1El ❑ 0 ❑ <br /> ❑ D F1 0 ❑ 0 ❑ ❑ <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 hi this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:/{/1,4 / "``'" ' Date: /2 - <br /> Tanknology Inc. 11000 N.MoPac Expressway,Suite 500,Austin,Texas 78759 <br />