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Y <br /> SWRCB,January 2002 Page—L of <br /> Secondary Containment Testing RepotForm <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of tH;^r--t^--i Nom„Ito f^;'1T17,-mmnnxontc tvvted The completed form, written testprocedures, and <br /> printouts from tests(j Chevron#20-5117 wnerloperator for submittal to the local regulatory agency. <br /> 755 S.Tracy Blvd. STI®N <br /> ra <br /> cility Name: Tracy,Ca 95376 Date of Testing: 3 -7mcility Address: SB 959 Nick Harvey#N11057cility Contact: - -- - --- <br /> Date Local Agency Was Notified of Testing : 2 <br /> Name of Local Agency Inspector(rfpresent during testing): <br /> 2. TESTEI�G CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: Al e< vc ICC# S"ll S"-2 7 <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,c10,C21 /D40 Haz License Number: 300345 <br /> n. <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepaiNot Repairs <br /> Component Pass Fail TestedMade Component Pass Fail Tested Made <br /> ��� ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 64. 7 c ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> , e 9-rte 19 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> >i-� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATI®N OF TECBNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of uay knowledge,Phe facts stated in this document are accurate and in fill compliance with legal requirements <br /> Date: .7- <br /> Technician's Signature: � ' � �-�� <br />