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Page I of 7 <br />Secondary Containment Testing Report 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 components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owteer/operator for ,submittal to the local regulatory agency. <br />BP/Arco #02186 2005 OCT 13 PV 12: l 4 <br />Facility Name.3212 N California <br />Facility Address: StoCkton, CA. 95204 <br />Facility Contact: N04731Phone: ' L I' A R r L N T <br />— SB 989 Testing <br />Date Local Agency Was Notifieu <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: tb r -F D RD a R1 O M <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 Component(s) Date Training Expires <br />SUPPLIED UPON REQUEST <br />'_ gIFMMARV CSF TFST RF.gIJI.TS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />97 -AA TU A8- NE zu-"P <br />® <br />❑ <br />❑ <br />❑ <br />op (-,5-6 <br />® <br />❑ <br />❑ <br />❑ <br />IT scP+Aot3 sU*ti <br />[51 <br />❑ <br />❑ <br />❑ <br />of) C -7- <br />® <br />❑ <br />❑ <br />❑ <br />11T,Jf-61Nf- bvlA <br />R1 <br />El <br />El <br />El <br />oouCTsMWaDA <br />PP <br />[:]0 <br />❑ <br />❑ <br />gl-M rtt1 svM <br />❑ 1 <br />❑ <br />❑ <br />7stp1A0a. SUPPA <br />P,p,#,jk <br />0 <br />❑ <br />❑ <br />❑ <br />Z • & I +-top Felt s U ►�* <br />E <br />❑ <br />❑ <br />❑ <br />q 1 Pxo as C.T &er.S+JoA <br />19. t, <br />❑ <br />JR <br />❑ <br />❑ <br />Fill m <br />® <br />❑ <br />❑ <br />❑ <br />'8;Arr \GT <br />® <br />❑ <br />❑ <br />❑ <br />gZ-1 Furl ,avc,Kf.T- <br />tia <br />❑ <br />❑ <br />❑ <br />141 Ak,\oukcr <br />❑ <br />❑ <br />❑ <br />Es 11 gvct5 rt' <br />Cid' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />7_3 f -5K BJ X£T <br />R <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />F, it F--rM <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />-7- 1. UAPot- 6UCK9 1- <br />l9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0--- <br />97-Z_ utA POO- 6 0 tKC-T <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />$7- 3 POR- 8,)-CW4 F T <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 �P�► oct— K E'r <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UD t -Z <br />g3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />JD 3. <br />5d 1 <br />❑ <br />❑ I <br />❑ <br />I <br />❑ I <br />❑ I <br />❑ 1 <br />❑ <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:7- 12, -DY <br />V _� <br />