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Feb. 23, 2015 11 : 11AM No. 5147 P. 3 <br /> SWRCB,January 2002 a <br /> c <br /> Secondary Containment Testing Report Form <br /> 3 2015g <br /> This form is intended for use by contractors performing periodic testing of USTsecondary containment systems. Use the <br /> appropriatepages of this form to report results for all components tested. The completedform,Written testpr <br /> printouts from testsif aV WAL <br /> pplica$le),should 8e provided to the facility owner/operator for su$mittal to the locaX <br /> e, aFNT <br /> ft <br /> 1. ]FACT ATY INFORMATION <br /> Facility Name: 2 9 p Date of Tes Z-i 9-I S <br /> Facility Address: ,3 y Rj, •-.� <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local.Agency Inspector(ifpresent during testing): <br /> 2. TESTWGCONIRACTORINFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: ,4R a.r ICC# S <br /> Credentials: 0 CSLB Licensed Contactor D SWR03 Liceiased Tank Tester <br /> License Type- A,B,clO,C21/D40 Haz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Conn onent(s) Date Trainin E ices <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component ]Pass )Fail Not Repairs Component Pass JFatl Not Repairs <br /> Tested Made Tested Made <br /> 7-P swopv 09 ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> 9e P9 o ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ 0 ❑ 0 ❑ ❑ 0 0 <br /> D ❑ ❑ ❑ ❑ 0 0 ❑ <br /> 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> 0 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 0 ❑ ❑ ❑ D <br /> ❑ 0 D 0 0 ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ 0 <br /> D ❑ 1 ❑ ❑ ❑ ❑ ❑ ` ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion oftests: <br /> CERTIFTCATION OF T)ECMICIAN RE,SPONSI BLE FOR CONDUCTING THIS TESTING <br /> Tb the best of my knowledge,the facts stated in this document are accurate and M full compliance with legal requirements <br /> Technician's Signature: Date: <br /> Received Time Feb. 23. 2015 11 : 21AM No, 8179 <br />