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Page ( of �— <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 (if aF � � ' ' - ner/operator for submittal to the local regulatory agency. <br />BP/Arco #02186 TION <br />Facility Name: 3212 N California <br />Facility Address: <br />Stockton, CA. 95204 Date of Testing: o . <br />MUM <br />Facility Contact: N04731R — SB 989 Repairs <br />Phone: <br />Date Local Agency Was Notified of Testing: DEC 0 -1 2004 <br />Name of Local Agency Inspector (if present during testing): NA <br />2. TESTING CONTRACTOR INFORMATION <br />ENVIRONMENTAL HEALTH DEPT. <br />Company Name: Wayne Perry Inc. <br />Technician Conducting Test:L� <br />Credentials: ® CSLB Licensed Contractor ❑ §WRCB 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 />I SUPPLIED UPON REQUEST <br />'I_ gITMMARY OF TF,ST RF,SITi.TS <br />Component <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: H <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: H <br />