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Page of <br />Secondary Containment Testing Report Forma <br />This form 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 tes, Chevron # ility owner/operator far submittal to the local regulatory agency. <br />1960 W 11th St RMATION <br />Facility Name: Date of Testing: ajr.-� <br />Tracy, Ca <br />Facility Address 05056 SS959 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): NA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry Inc. <br />Technician Conducting Test: 4/1 C 9R Vi77 :r <br />Credentials: ® CSLB Licensed Contractor ❑ 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 />,� <br />► <br />0�0� <br />s�:' <br />0000 <br />OL7��� <br />0000' <br />___mum <br />u00umm0 <br />ME-MM0 <br />' <br />umm0 <br />um0 <br />amm� <br />-�.. <br />um00 <br />000; <br />uQQQI <br />MMM�I <br />--___mums <br />©o�ao <br />0000� <br />mmm <br />