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0 <br />SWRCB, January 2002 Page of <br />Secondary Contain M*ent Testing Report Form <br />This form is intended for use by contractors perfarmingp,r;odic testing of UST condary containment systems. Use the <br />appropriate pages ofthis form to report results for all components tested The completed form, written test procedures, and <br />l <br />printouts from tests Arco #05450 owner/operator for submittal to the local regulatory agency. <br />1617 W. Fremont CATION <br />Facility Name: Stockton, Ca jDate ofTesting: 5---Ze--j41 <br />Facilit3r.Address: Nick Harvey <br /># 10073 SB 989 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): <br />Company Name. Wayne Perry, Inc <br />Technician Conducting Test:VI&JI- llwgrlel-1 ICC# <br />Credentials: 0 CSIB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A, B, clO, 300345 <br />11111jai i, i I :U C21 / D40 Haz License Number. <br />Manufacturer Training <br />Manufacturer component(s) Date Training Exfres <br />Furnished Upon Request <br />i t I 1 1' Y .�� <br />I' i <br />I I. l: <br />i � I ! t �.®� <br />I. l <br />i I, I' <br />r-/ <br />.- <br />c�r�►-��oaoo <br />.., <br />_ <br />-low= <br />M <br />L "INN <br />ZVW�W,�-a <br />= <br />IBM= <br />0 <br />mom <br />NEW <br />a <br />VS. <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECIINICIAN-RESPONS11BLE FOR CONDUCTING TMS 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: <br />Date: -<- 7-9: - /c, <br />