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Seconda Containment Testing RepoFIt Form a� <br /> Thisform 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 jor all components tested The completed form, written test procedures, and <br /> printouts from tests(if appli Costco#658 /operator for submittal to the local regulator,ngcnrv. <br /> 3250 W.Grant Line IN <br /> Facility Name: Tracy,Ca 95304 Date of Testing: 7 <br /> Facility Address: Nick Harvey <br /> Facility Contact #09009 SB 989 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: Alle/f �R _ <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Com vents) Date Trainin Ex ires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Klle/,�R,7a <br /> Pass Fail Not Repairs Component pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 'i ❑ ❑ 0 ❑ et s.+r (t0 ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ' ® ❑ ❑ ❑ <br /> 9 ® ❑ ❑ rr 8P-L fa ❑ ❑ ❑'® ❑ ❑ Y, ❑ ❑ ❑ <br /> g,. ® ❑ ❑ s, 0 1 ,0 1 ❑ I ❑ <br /> s-4 la ❑ Y ❑ 1 ❑ <br /> ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ❑ El <br /> s- N ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> IR ❑ ❑ ❑ ❑ ❑ ❑ EJ <br /> T,;,- 11 11 El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑Y7- ® ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> _ tI � RtINS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1'0 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: 2 - .z 'y-Z) y <br />