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Work Order: 2250365 <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 /> printoutsfrom tests(ifapplicable),should be provided to thefacility owner/operator forsubmittal to the local regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Facility Name: G(��t/20/U 0 Date of Testing: 04L-/i'-O <br /> Facility Address: <br /> Facility Contact: Phone: vOcl 9 <br /> Date Local Agbncy Was Notified of Testing. <br /> Name of Local Agency Inspector(ifpresenr during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: (:7¢ ffer as �r,c• <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor. S WRCR Licensed Tank Tester <br /> License Type:C57, B, 061/D40, A.AZ A RIC Cld License Number: 22079 <br /> Iylanufa f�f'I'raining <br /> Manufacturer Co n s Date Trainin Bx fires <br /> I <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fall Not Repairs Component Paan Fall Not Repairs <br /> Tested Made Tested Made <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tests: <br /> C.ti'afe �ror.-t 71CSA4 /Klee t-� lit 10 9LS tY'�v�•t ct/� a �d e <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,/thee facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:__0 q-I <br /> Tanknology Inc. 8501 N.MoPac Expwy#400,Austin,Texas 78759 <br />