Laserfiche WebLink
? ? r Page of <br /> Secondary Conta>rn nellt Tes.ting Report Form ' <br /> This form is intended for;use by contractors performing pt?riodie testing of US7 secortda containment <br /> ry 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(; f erator/on <br /> o <br /> Twer or submittal to the local regulatory agency <br /> BP#02133 p g �v <br /> 2908 W Benjamin Holt Dr CATION <br /> Facility Name` _Stockton,Ca _ Date of Testing: —a�- <br /> FacitityAddress: 08,03 SB989 <br /> Facility Contact: _ Phone.• <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresentduting testlng): NA + <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: =s Wayne Perry Inc. <br /> Technician Conducting Test: <br /> L= <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester ' <br /> License Type: A B ASB C-10 HAZ D40 License.Number.300345 <br /> µManufacturer T'rainin r: <br /> Manufacturer Components} _ Date Irainin Ex ites <br /> SUPPLIED UPON REQUEST _ <br /> _ j <br /> 3. SUA04A.RY OF TEST RESULTS _ <br /> Component Pass Fail Not Repairs Component Pass gall Not Repairs <br /> Tested Made Tested Made <br /> gi- ❑ <br /> f-2 ❑ ❑ a <br /> El El. <br /> ❑ <br /> ❑ © ❑ i <br /> ❑ ❑ ❑ ❑ ❑ { <br /> i <br /> ❑ ® ❑ ❑ <br /> ❑ ❑ I <br /> i <br /> If hydrostatic testing was performed,describe at was done'with the water after completion of tests: <br /> �f <br /> CERTIFICATION OF IECHNICIAN RESPONSIBLE FOR CONDUCIING THIS TESTING ' <br /> To the best of my knowledge,the.facts stated in this docunteut are accurate and in full compliance with legal requirements <br /> Technician's Signature:,,"�J� f� <br /> t-c /41a Date: <br />