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r <br /> SWRCB,January 2002 • • Page j of-3— <br /> Secondary Containment Testing Report Foran <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report resultsfor all components tested The completedform, written testprocedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: eVITC C d 1>3 Date of Testing: <br /> Facility Address: Gi& IE f44djjFpZv. Jcft—l),V e ,4 <br /> Facility Contact: P one: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: k I C k Y4 Rie ✓ ICC# 66"//573 <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,c10,C21/D40 Haz License Number: 300345 <br /> Manufacturer Tramine_ <br /> Manufacturer Component(s) Date Training E fres <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested I Made <br /> o Sc, ®. ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thhe facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ,✓l/ �� 1 Date: <br />