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Page of �— <br />Secondary Containment Testing Repo*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 componer�ts tested. The completed form, written test procedures, and <br />printouts from tests (if a[ -r l to the local regulatory agency. <br />BP/Arco #02186 Z00ge I� <br />Facility Name: 3212 N California S N j0;, , Vesting: o <br />Facility Address: Stockton, CA. 95204 ENYIP%0N <br />Facility Contact: N04731R — SB 989 Repairs HEADLTH E !, p T M E N T <br />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 />L� <br />Credentials: ® CSLB Licensed Contractor <br />❑ tWRCB Licensed Tank Tester <br />License Type: A B ASB C-10 HAZ D40 <br />Manufacturer <br />License Number: 300345 <br />Manufacturer Training <br />Component(s) Date Training Expires <br />SUPPLIED UPON REQUEST <br />Wm� <br />0�0� <br />-3_ SITMMARY OF TEST RESULTS <br />Component <br />Repairs <br />Made <br />'� ►�o3uR u� 'MA <br />Wm� <br />0�0� <br />1y� 1I""� * W <br />Ia <br />MM� <br />it <br />If hvdrostatic testinp- 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: <br />