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Page 1 of <br /> Secondary Containment Testing Re o*orm <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 a '' •vner/operator for submittal to the local regulatory agency. <br /> ARCO/BP—#04932 TION <br /> Facility Name: 16 E Harding Way Date of Testing: <br /> Facility Address: Stockton, CA. 9.5204 <br /> Facility Contact: N04981R - SB 989 Repairs Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: <br /> Credentials: E CSLB Licensed Contractor ❑SWRCB Li ensed Tank ester <br /> License Type: A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Training <br /> Manufacturer Component(-) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component P� Fail Not Repairs <br /> Tested Made Tested Made <br /> -Z - ❑ ❑ .e' ❑ 101 ❑ ❑ <br /> ❑ ❑ ❑ 01 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 01 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ [] 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 01 ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> ❑ 01 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> O ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> O 1 ❑ 1. ❑ 1 ❑ ❑ 1 ❑ 1 ❑ <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 in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: \<�l 0 2� <br />