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11 <br />Page ' of 5 <br />SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors pe far all gper components sting Of U tested The completed farrrc,secondary awri en inment te t procedur s, and <br />appropriate pages of this forma P .. .= r •11 owner/operatorfor submittal to the local regulatory agency. <br />printouts from tela Arco #05450 <br />1617 W. Fremont TIQN. <br />Stockton, Ca � Date of Testing:7—.Ir- <br />Facility Name: <br />NickHarvey <br />Fac Address # 10073FSB 989 �uVu <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector gprsent during testing): <br />2. <br />am <br />Company Name: Wayne Pe�11-ncICC# <br />Technician Conducting Test l SWRCB Licensed Tank Taster <br />Credentials: ❑ CSLB Licensed Contractor License Number. 300345 <br />License Type: A, B, c10, C211 D40 Haz <br />Manufacturer Trainin Date <br />manufacturerCom oven S <br />Furnished Upon Request <br />If hydrostatic testing was performed, describe what was aone win► <br />CERTIFICATION OF TFCHMCL4Ndocument �accurate RESPONSIBLE <br />FOR <br />Rad iNDU TING T H with ST I N requirements <br />TO the best of my knowledge, the,�acts stated in Plaas <br />Date:_ <br />Technician's Signature: <br />