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Page_ / of <br /> s � <br /> Secondal l Containment Testing Reps � m <br /> This form is intended for use by contractors performing periodic testing of UST secondary con <br /> appropriate pages of this form to report results for all components tested. The completed form, written tes o e nd <br /> printouts from tests(if c I wner/operator for submittal <br /> �JHH"P 1 regulatory agency. <br /> Conoco Phillips #2708671 ,TION 2005 <br /> 8606 Thornton Rd. Date of <br /> Facility Name: Stockton, CA. 95209 vl $ <br /> Facility Address: N04598—SB 989 Testing Phone: <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: -k5r 4.N <br /> Credentials: ®CSLB Licensed Contractor E] SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Com onentk) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Tested Made <br /> ❑ ❑ ❑ ❑ <br /> q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 u�a,� ❑ ❑ ❑ ❑ <br /> ❑r—E] O❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ <br /> 143 ❑ El ❑ [I El El El <br /> ❑ ❑ ❑ ❑ <br /> o 0 <br /> 0 ❑ El El-� --- El 1:1 11 <br /> �y ❑ ❑ ❑ <br /> El ❑ 11 0— ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ o ❑ ❑ <br /> ❑ El ❑ ❑ ❑ ❑ ❑ El <br /> ❑ ElEl ❑ El ❑ ❑ ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: $ v <br />