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SWRCB,January 2002 Page/of <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performingperiodic testing of USTsecondary containment systems. Use the <br /> appropriate pages of thisform to report results fn-771 ---ted. The completed form, written test procedures, and <br /> printouts from tests(f Arco 902186 wner/operator for submittal to the local regulatory agency. <br /> 3212 N California TION _ <br /> Facility Name: Stockton,Ca Date of Testing: g'_3,E> 1 <br /> Facility Address: Nick Harvey <br /> Facility Contact #10072 S19.989 phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: ,�() , 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 Trainiu <br /> Manufacturer Component(s) Date Training Expires. <br /> Furnished Upon Request <br /> 3. SUN MARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fad Tested Made Component Pass Fail Not <br /> Made <br /> 7 v ..� - - M- ❑ ❑ ®, El ❑ 11 El <br /> V7 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9. El 11 El ❑ ❑ El ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ F1 ❑ ° ❑ <br /> ❑ ❑ ❑ ❑ -- ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El 11 El El ° ° ° ° <br /> ❑ ❑ ffl-1— <br /> ❑ ❑ El 11 El❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECI1ICL4N RESPONSIBLE FOR CONDUCTING THIS TFSTING <br /> To the best of my knowledge,tltefacts stated in this document are accurate and in full compliance with legal requirements <br /> •' � Date: <br /> Technician's Signature: "(", "�`�— <br />