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S WRCB,January 2002 4 .i Paget of 3 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic 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 test procedures, and <br /> printouts from tests(rf a Costco#658 ner/operator for submittal to the local regulatory agency. <br /> 3250 W. Grant Line TION <br /> Facility Name: Tracy,Ca 95304 Date of Testing: 3 z/, o q <br /> Facility Address: Nick Harvey <br /> Facility Contact: #09009 SB 989 Phone: <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: N/C'..0 1,4 'Vc 7w ICC# <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B, c 10, C21 /D40 Haz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Comonent Pass Fait Not Repairs <br /> p <br /> Tested Made Tested Made <br /> V P, is ❑ ❑ 9, ❑ ❑ ❑ ❑ <br /> L( c - i �§ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: K Date: f- <br />