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~ Page if of r/ <br /> RECERESecondary containment Testing Repo orm Thisform is intendedfor use by contractors performing periodic testin o UST seconda containment stems. D <br /> g f secondary �' IJse�i �� D <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedureAcitt4 <br /> Printouts front tests(if app ?r/operator for submittal to the local r&Ift age11cy20�� <br /> Arco 6313 [ON p�. lvltiJENrHFAL <br /> 1100 S. Main St. t S H <br /> Facility Name: Manteca, Ca 95337 Date of Testing: a_/ 7_ D S <br /> Facility Address: N05789 SB 989 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 INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: V&7.,- <br /> Credentials: <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 /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 1 ® ❑ ❑ ❑ IrZ ® ❑ ❑ ❑ <br /> , ► g ® ❑ ❑ ❑ 19 ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ® ❑ ❑ 1 ❑ <br /> r s ® ❑ El El ® El El <br /> If M ❑ ❑ ❑ N ❑ ❑ ❑ <br /> 9/ @I ❑ ❑ ❑ y/ [A ❑ ❑ ❑ <br /> r f7 ❑ ❑ ❑ til( 99 N ❑ ❑ ❑ <br /> qy ® ❑ ❑ ❑ g7 91 ❑ ❑ ❑ <br /> 91 ❑ ❑ ❑ t q-7 10 ❑ ❑ ❑ <br /> KD � 1- ® ❑ ❑ ❑ a � el ❑ ❑ ❑ <br /> t ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ti K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: <br />