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Work Order: 2237782 <br />S WRCB, January 2002 <br />Secondary Containment Testing Report Form <br />This form is Intended for use by contractors performing periodic terting of UST secondary containment systems. Use the <br />appropriate pages of this form to report resvits for all components rested The crmpleted faM written dart procedures, and <br />printouts from tests (rf applicable,) should be provided to the facility owner/operator for submittal to the focal regelatnry agency. <br />I. FACILITY INFORMATION <br />Facility Nacrei-t.r.0- DateofTesting: 7 "/ 3-0 <br />Facility Address: �r '� ry °� LA <br />Facility Contact Phone: (w A1sr t <br />Date Local Agency Was Notifad of Testing: --7- — O <br />Name of Local Agency Rtspector (rpreserrt during testing): <br />2. TESTING•CONTRACTOR MFORMnON- <br />COM2fMX Name: <br />Technician Conducting Test: <br />Credentials: O CSLB Licensed Contractor ❑ SWRCU Ucen!cd Tank Tester <br />License type: License Number: <br />Manufacturer Training <br />Maatufaetucer Co nt s Data Trainin fix ices . <br />3. SUNEWAR•Y OF TEST RESU TS <br />Not Repairs M t Repairs <br />Canilram"t Paas Fail 'ested Made Component Pass Rail .Vested tyrra'jde <br />.P ►i X ❑ ❑ ❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />❑ ❑ O <br />❑ ❑ ❑❑7 <br />❑ ❑ ❑ <br />l] <br />' ❑y ❑ ❑1 <br />❑ <br />G ❑ ❑ <br />❑ <br />❑ ❑ O❑ <br />O ❑ D <br />r"J <br />❑ ❑ ❑ <br />❑ <br />if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />-P ` � l<i ®vt flr. r rr7 -ar n ' <br />CERTIFICATION OF TECHNICIAN RESPONS1BLE FOR CONDUCTING THIS TESTING <br />To the best of my irnowledge, the facts stated in this document are accufate and in fur! camplhrhes with legal requirements <br />O`de: <br />' � <br />Technician's Signatme: l'!J __ ��i _ <br />Tanknology-NDE 8900 Shoal Creek, Building 200 Austin, Texas 78757 <br />