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� t <br /> Page 1 of <br /> Secondary Containment Testing Report .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 fi"om tests(if applicable' atorfor submittal to the local regulatory agency. <br /> Chevron#208118 <br /> Facility Name: 3355 E Hammer Ln Date of Testing: //P_/9_Z7 <br /> Facility Address: Stockton, Ca <br /> Facility Contact: 907350 SB989 Phone: <br /> Date Local Agency Was Notified of Testing: i <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: 101el< <br /> I <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester I <br /> License Type: A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Training 1 <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made j <br /> I� ❑ ❑ ❑ ❑ ❑ ❑ ❑ I <br /> al ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ❑ D ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ea ® <br /> 19 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> u jo of ►r.� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a e <br /> 7--y ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ab .4, ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ao 7- ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e e �.,rte ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T7 l ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ® P �i I� ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> El 0 El <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 docutnent are accurate and in fill compliance with legal requirements <br /> Technician's Signature: Date: 10�. �� 7 <br /> i <br />