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C-econdd& Containment Testing RepceForm o <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 farm, written test procedures-, and <br />printouts from tests (if applicable), should he provided to the facility owner/operator for submittal to the local regulatory agency. <br />I <br />Facility Name: <br />Facility Address: <br />Facility Contact <br /># BP 02130 <br />7906 N. El Dorado St <br />— Stockton, Ca <br />— 08151 <br />Date Local Agency Was Notified of T( <br />Name of Local Agency Inspector ffpresent awing testing: <br />NA <br />to of Testing. S - z C .. 4f -J I <br />Company Name: Wayne Perry Inc. <br />Technician Test: Conducting <br />C, 114j;? Vz- <br />Credentials: Z CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A B ASB G-10 HAZ D40 License Number: 300345 <br />Manufacturer TraininLy <br />Manufacturer Component(s) Date Training Expires <br />SUPPLIED UPON REQUEST <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECM11CL&N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the, facts stated hi this document are accurate and infill compliance with legal requirements <br />Technician's Signature:�,%Date: 4- ._f> 7- <br />WIM-1- <br />'.7NN <br />Kim <br />WWM <br />M, <br />mom <br />■ <br />vtot <br />: <br />WMEM <br />0 <br />M <br />W <br />0 <br />MOM <br />rc�or.■w' <br />iii <br />=w� <br />■ <br />uou� <br />■ <br />MOM <br />UN <br />M <br />■ <br />KIM <br />0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECM11CL&N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the, facts stated hi this document are accurate and infill compliance with legal requirements <br />Technician's Signature:�,%Date: 4- ._f> 7- <br />WIM-1- <br />'.7NN <br />