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• Work Order: 2250365 <br /> Tom'' <br /> SWI2CB,January 2002 Page / of Z <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 the facility owner/operator for submittal to the local regulatory czgency. <br /> I. FACILITY INFORMATION <br /> Facility Name: G f/-A?!,e0A1 At' Z 0 9/6;z Data of Testing: 4q44--/L-O l" <br /> Facility Address: / <br /> Facility Contact: Phone: Z-O q * Z <br /> Date Local Agbncy Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: -1¢/¢/er Z;;,- -..c- <br /> Technician Conducting Test <br /> Credentials: CSLB Licensed Contractor. S WRCB Licensed Tank Tester <br /> UcenseType:07, B, C61/D40, HAZ A HIC Cld License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Co s Date Training Expires <br /> O <br /> I <br /> i <br /> 3. SUA1M"Y OF TEST RESULTS <br /> Comp000at paw PaH NA ltopat-Tested composeat Pam Fail Not RMsde <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> /.cJar{e ow-t SAS 4r eta CUL i•t c, /04 is - �v c �• e <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,/ghee facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: / U��''t - Date: <br /> Tanknology Inc. 8501 N.MoPac Expwy#400,Austin,Texas 78759 <br />