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5 Page t of I <br /> h"? <br /> Secondar0containment Testing Repo Worm <br /> This farm 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 1?A nay W-- <br /> Facility Name: Arco #2133 Date of Testing: <br /> Facility Address: 2908 W. Benjamin Holt Dr. <br /> Facility Contact: Stockton, CA. 95207 Phone: <br /> Date Local Agency Was Notified o N05127 — SB 989 Testing <br /> Name of Local Agency Inspector(ij p,raC.tt uuring resting): NA <br /> 2. TESTING CONTRACTOR INFORMATION D <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: iD�., Q m t6{fit, MAY 0 � 2005 <br /> Credentials: ID CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 <br /> License Number:300345 SAN j1DA 41I1y COUNTy <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> Component Pass Fail Not Tested Repairs <br /> Made Component Pass Fail Tested Made <br /> � �`t'�7L a �r ® ❑ ❑ ❑ � a+e r�`•C�- �1 ❑ ❑ ❑ <br /> El 11 <br /> e vac 3L Va ❑ ❑ ❑ U.P le _ ;- z Cr7 O ❑ ❑ <br /> fit' ra L ❑ ❑ ❑ 1 e ` 3 ❑ ❑ ❑ <br /> _ " t Vit," � ❑ O ❑ e �- �, � ❑ ❑ ❑ <br /> X7'`2 ❑ ❑ EltpC .2 ® ❑ ❑ ❑ <br /> 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> > ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> &Z SItai i l Svi dLl Ek ❑ ❑ ❑ <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 /> Date: <br /> Technician's Signature _ ; �' <br />