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__ Page of <br /> Secondary -;ontainnlent Testing Report ,orin <br /> This fonn 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 apper/operator for submittal to the local regulatory agency. <br /> ARCO/BP — 04932 [ON <br /> 16 E HARDING WAY - <br /> Facility Name: <br /> STOCKTON, CA 95204 Date.of Testing: L> r' —O <br /> Facility Address: NO SB989 TESTING <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION1141 GQ- T, <br /> Company Name: Wayne Perry Inc. ENVIRONMENTAL HEALTH EPT. <br /> Technician Conducting Test: <br /> Credentials: M CSLB Licensed ntractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 0 <br /> SI <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> r ❑ ❑ ❑ 9 IN ❑ ❑ <br /> ip ❑ ❑ ❑ t , ❑ D <br /> 11 <br /> >z ❑ ❑ ❑ i . ® [I El -0 <br /> ., ip 1 ❑ El Eli F3 ❑ El ❑ <br /> El El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ D <br /> D ❑ wd ❑ ❑ ❑ ❑ ❑ <br /> a, 1 ❑ ❑ � D ❑ D ❑ ❑ <br /> --7 ,1 ❑ ❑ Gtr D ❑ O ❑ ❑ <br /> �l ❑ ❑ 51 D ❑ D ❑ ❑ <br /> p+ ❑ ❑ D ❑ ❑ ❑ ❑ <br /> W1 ❑ ❑ ❑ ❑ ❑ ❑ I ❑ <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: 00 <br />