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Page of <br /> Secondary Containment Testing Repo Form <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 tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> Facility Name: Chevron #208118 Date of Testing: <br /> Facility Address: 3355 E. Hammer Ln. <br /> Facility Contact: Stockton, CA. 95212 Phone: <br /> Date Local Agency Was Notified c N04765 — SB 989 Testing <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. 2 2-994 <br /> Technician Conducting Test: <br /> Credentials: ®CSLB Licensed Contractor SWRCB Licensed Tank TesterFRAllpa <br /> UANAQUIN CUNI Y <br /> wiVIVILAM IIAL MEAL -PT <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. SUMMA RY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> / ? 'N/V''� e--B-- Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> s117-u ❑ ❑ ❑ ❑ <br /> ER-7 <br /> 91/ <br /> / ❑ ❑ ❑ D ❑ ❑ ❑ <br /> e [ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 03 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V -,Ee K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e- e-f N ❑ ❑ ❑ <br /> El <br /> ❑ ❑ <br /> .� e zL ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> .v A" IN ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C, _ �_ Z ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> p c Y ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> X C /-, I Id ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <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 /> Technician's Signature: �:,.. Date: 9 — / � C <br />