Laserfiche WebLink
t <br /> Page J—, <br /> Secondary Containment Testing Report Form <br /> Thi.r fonn is inlended for use by contractors performing pe+iodir testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components,lested The completed form, written test procedures,and <br /> printoutsfrom irsts(if applirahio! chro.+,+t..._ ..:a r-- �er/operator for submitral to the local regulafo+y .agenry- <br /> Arco #2133 (ON <br /> Facility Name_ 2908 W. Benjamin Holt Dr. nate of Testing: — Z.-7-OF <br /> Facility Address: Stockton, Ca. 95207 <br /> Facility Contact: N0512*-SB 989410MMM Phone: <br /> DateLocal Agency Was Nounea or Testing: <br /> Name of Local Agency Inspector(ifpresent present during testing): NA <br /> 2. TESTING CONTRAC'T'OR INFORMATION _ <br /> Company Name: Wayne Perry Inc_ <br /> Technician Conducting Test <br /> Credentials ®CSLB Licensed Contractor x ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number_300346 <br /> Manufacturer Traifitu oil <br /> Manufacturer Com nent(s Date Training]expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUAMARY OF TEST RIESULTS <br /> Not I <br /> Component <br /> a <br /> Teo�d made Component Na pail T Mtepairg <br /> Made <br /> .rG ❑ ❑ t ❑ ❑ <br /> ® ❑ H ❑ Q <br /> ❑ ❑ C117 Z ❑ 1 ❑ <br /> r t 7--! ❑ ❑ ❑ I erl ❑ 1 ❑ 1 ❑ <br /> I! C] ❑ 13et I a P. '.S 5{c®- Li Li 1 O <br /> 7 ❑ EJ 11 -t t dP`tti ��. ❑ 1 11 ❑ <br /> !/ Q LJ ❑ ❑ ❑ 13 l3 <br /> G ❑ 13 ---- ❑ ❑ 110 <br /> ❑ C] ❑ 01 ❑ ❑ <br /> ❑ ❑ ❑ ,toy. e Su EJ ❑ ❑ <br /> D Q ❑ ❑ 10 1 CI ❑ <br /> ❑ ❑ ❑ 101 ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TI!;C14NICUN 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.- ,.5;i : Date: Z _ <br /> i <br /> LZO/t:00[(j %yd SC:ST NOW 500Z/rZ/0T <br />