COMPLIANCE INFO_2002-2005 - Laserfiche WebLink

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Page� of O Secondar-*ontainment Testing Repoloorm This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applical BP Arco # 02130 erator for submittal to theHWader I tT + t 4 Facility Name: 7906 N EI Dorado Street Date of Testin : G tj`i'i T v Stockton CA 95210 g EALTH DJEP4RTNk Facility Address: r Ejqj Facility Contact: N05431- SB 989 Testing phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(if present during testing): NA 2. TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry Inc. Technician Conducting Test: All e " yz Credentials: N CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A B ASB C-10 HAZ D40 License Number:300345 Manufacturer Training Manufacturer Component(s) Date Training Expires SUPPLIED UPON REQUEST 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made ❑ D ❑ u -7-5' ® ❑ ❑ D ❑ D ❑ ,,P,Q ® ❑ ❑ ❑ r rV1 7 g M D ❑ ❑ IN ❑ D ❑ v/ 69 ❑ ❑ ❑ . I9 ❑ D ❑ ❑ IN D ❑ r r , Is ❑J D D -z ❑ IN ❑ ❑ .R7 ❑ D D .. �.� ® D D ❑ , , y7-i ® ❑ ❑ ❑ _ 10 ® D ❑ ❑ - 3 IN I ❑ D ❑ 9i ❑ im ❑ ❑ 91 P9 D D. ❑ .7-, IO ❑ ❑ D V -1 8wkc76 T,7-- 0 ❑ ❑ D y s'7-z ® D D ❑ f 7"L ® D D ❑ 5,7- 3 ® D ❑ 11 7.3 LTJ D D ❑ 91 ® D D ❑ 9/ I9 ❑ ❑ ❑ i-z lel D D D ❑ D 11 D D M ❑ El D D 11 00 D D O O D D D If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: