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t ! Page <br /> Secondaocontainment Testing Repo* Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. hath2®0 5 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test FNInd <br /> printouts from tests(if applicable, Arco #2133 itor for submittal to the local(i� U14OL N <br /> 2908 W. Benjamin Holt Dr. <br /> �EPVICES <br /> Facility Name: Date of Testing: <br /> Facility Address: Stockton, CA. 95207 <br /> Facility Contact: N05127 — SB 989 Testing 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: lek <br /> Credentials: ®CSLB Licensed Contractor 0 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 Fait Not Repairs Cam Not Repairs <br /> po Tested Made Component Pass Fail Tested Made <br /> T7 72M P 19 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ �t ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ® ❑ O ❑ ❑ ❑ <br /> ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ [J ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ta ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ O ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 10 ❑ ❑ ❑ <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 /> .10 <br /> Technician's Signature: Date: <br />