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Feb. 23. 2015 12: 36PM No. 5149 P. 3 <br /> SWRCB,fanuary2002 Page ofq <br /> Secondary Containment Testing Report For <br /> This form h intendedfor use by contractorsperformingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form,written testprocedures, and <br /> printoutsfrom tests Ofapplicable),should be provided to the facility owner/operator for submittal to the'local regulatory agency- <br /> 1. <br /> gency1. ]FACILITY IWORNIATION <br /> Facility N'ams: 2o Tj j7 Date of Testing: .2 _Z <br /> Facility Address: U b. I R A-C ek <br /> Pacility Contact: Phone: <br /> Data Local Agency Was Notified of Testing: ii Name o£Loca1 Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR WORMATION linfUlam <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: &leg Ig.4,g v c✓ ICC# p S 7,7 f- <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tard<Tester <br /> License Type: A,B,c10,C21 /D40,Iaz License Number: 300345 <br /> Manufacturer TratnQ <br /> Manufacturer component(s) Date Training Expires <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component ]Pass pail Not Repairs Component Pass Fall Not Repairs <br /> Tested Made Tested Made <br /> SF< 7 ❑ Q ❑ D• ❑ ❑ ❑ <br /> N ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> AI1-7 M ❑ ❑ ❑ d ❑ ❑ ❑ <br /> I/ IM ❑ ❑ ❑ ❑ D ❑ ❑ <br /> :rLf. f ❑ ❑ ❑ ❑ ❑ D ❑ <br /> ra 91 ® D ❑ ❑ ❑ ❑ ❑ Q <br /> ❑ ❑ ❑. ❑ ❑ ❑ ❑ D <br /> ❑ ❑ Q 0 ❑ D ❑ ❑ <br /> ❑ ❑ Q 0 ❑ Q ❑ ❑ <br /> ❑ D D ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ 0 0 ❑ ❑ <br /> ❑ Q ❑ El ED <br /> ❑ ❑ El <br /> If hydrostatic testing was performed,describe what was dome with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CON DUCT)NG TTS TESTING <br /> To,the best of my knaWedge,the facts suited in this document are accurate and in fall com�,liarace with legal wequirements <br /> Technician's Signature: Date: .7- 70- 15, <br /> Received Time Feb. 23, 2015 12: 46PM No. 8183 <br />