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Fage_ I of <br /> Secondt, y Containment Testing Rept 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION 2005 <br /> Facility Name: BP Arco-00595 Date of Testing: - C)5— <br /> Facility Address: <br /> 6100 N. Hwy 99 t t <br /> Facility Contact: 6ne{ i y p.-P <br /> Stockton, Ca 95205 _ <br /> Date Local Agency Was Nc N05667 SB 989 Testing <br /> Name of Local Agency Insp r <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: J e)")I C <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 97 1) FOP ❑ lK ❑ 11 0P C a--k- 1 - 2- ❑ K ❑ ❑ <br /> S <br /> 7 2 r-Ce w i ❑ ❑ ❑ p C Pc-`� 3 —Lj 10 ❑ ❑ ❑ <br /> sccL,,-& ,PL Nr ❑ ❑ ❑ upC 5-- �" ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 0C- ❑ Nr ❑ ❑ <br /> $ I -r.��6•� S�w.P ❑ ❑ ❑ ❑ El ❑ El <br /> TuC t"4- S✓ I� 11 11 O $ f;l ��Lk 6 Ct4e 19 [� ❑ ❑ <br /> �v ►��' sJ� ❑ El El Sl (t) V nr ;; ; C+ IR ❑ ❑ El <br /> EI ❑ ❑ ❑ ❑ ❑ ❑ <br /> 870 hi ❑ ❑ ❑ 97(2-) F:kk GO U ❑ ❑ <br /> V7 (2) F: S- SV ❑ ❑ ❑ 7 2 VC-Po v c ee ❑ ❑ ❑ <br /> Cu, s� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ q ,:::�ck k V C%---t+ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ Q vGPo g cry ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ <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: LJ _ �.�- Date: -0 S <br />