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I s Page of <br /> SecondaryContainment Testing Reporkorm <br /> This fohn 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 agency. <br /> 1. FACILITV INFORMATION <br /> Facility Name: ACCO #9600 Date of Testing: ' p - OJ <br /> Facility Address: 1250 N Wilson Way <br /> Facility Contact: Stockton, CA. 95205 Phone: <br /> Date Local Agency Was Notifiet N05114 — SB 989 Testing <br /> Name of Local Agency Inspector,, ___..- __...., ......11. <br /> 2. TESTING CONTRACTOR INFORMATION DR�flrP MR <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: �p-N V-i GLAeS <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number: 300345 SAN JOAOUIN CdUNTY <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Fail Not RepairsComponent Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ ❑ ❑ / r J"e%ee& ,$1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑- 91 Y . e' t ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ,rl ru ❑ ❑ ❑ <br /> 7 5e �� Gs7 ❑ ❑ ❑ g - / z ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ape F ❑ ❑ ❑ <br /> 8 ❑ ❑ ❑ 1,t im 7 - ❑ ❑ ❑ 1 <br /> ff7 lit J. e etWEIE] <br /> 6(bc F�-1 fel ❑ ❑ ❑ <br /> '="4 ay �rtie.E'C lt�c >s- /4 0 ❑ ❑ ❑ <br /> r, dXckz 'ick ❑ ❑ ❑ ❑ <br /> /`i// Jrt ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was perfo escribe 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: �¢y, ,, j Dater j <br />