Laserfiche WebLink
SWRCB,January 2002 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 Arco 902186 owner/operator for submittal to the local regulatory agency. <br /> 3212 N California IATION <br /> Facility Name: Stockton,Ca Date of Testing: 20..E <br /> Facility Address: Nick Harvey <br /> #10072 SR 989 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> — - I <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Tecbnician Conducting Test: V—)G—,& L ICC# <br /> Credentials: D CSLB Licensed Contractor D S WRCB Licensed Tank Tester <br /> License Type: A,B,c10,C21 /D40 Haz License Number: 300345 <br /> -- Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Fumished Upon Request <br /> i <br /> i <br /> _3. SUMMARY OF TEST RESULTS <br /> Not Repairs I Component Pass Fail Not Repairs <br /> Component Pass Fail Tested Made p Tested Made JJ� <br /> I <br /> ❑ ❑ ❑ 7/ :9 ❑ ❑ ❑ M <br /> Fr ❑ ❑ 11, ❑ W ❑ } <br /> El 11 <br /> 11 0 11 11 <br /> g? ❑ ❑ ❑ ,r 9/ u u ❑ 1i <br /> 41 ❑ ❑ ❑ v..,�� ��-r �l ❑ ❑ ❑ <br /> u c -z I� ❑ ❑ ❑ - Via- ❑ M ❑ ❑ <br /> ;I ❑ ❑ ❑ 7.2- ❑ ❑ <br /> �e. 9 L1 ❑ ❑ 1 ❑ ftp ❑ El i <br /> -7-j( M El L1 El �i=Lj El <br /> If hydrostatic testing was performed,descnbe what was done with the water after completion or tests: <br /> -- E <br /> i <br /> CERTIFICATION OF TECIMCIAN RESPONSIBLE FOR CONDUCTING TIMS TESTING <br /> To the best ofmy knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: r�i% _ Date:_ _ Z`� _/ i <br />