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Page / of_4- <br /> Seconda j Containment Testing Rept, Forl O OVEDD <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 tefAAybcoG�e?,O& <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory a en . <br /> 1. FACILITY INFORMATION EMRONMENT regulatory <br /> Facility Name: Arco # 6020 Date of Testing: <br /> Facility Address: 1711 E. Yosemite Ave. <br /> Facility Contact: Manteca, CA. 95336 Phone. <br /> Date Local Agency was Notified of N05116 — SB 989 Testing <br /> Name of Local Agency Inspector(i� <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: 7tiA�N to► , b IT-%Gt,L es <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 /> lia ❑ ❑ ❑ qf F,(t ❑ ❑ ❑ <br /> IK ❑ ❑ ❑ Kb C- / - z ® ❑ ❑ ❑ <br /> 8 Std a�1 [� ❑ ❑ ❑ 01 ❑ 1 ❑ <br /> L E� ElElEli c — l�- O 1 ❑ ❑ <br /> �57 R ❑ ❑ ❑ Lt DC 9 - /4 ❑ ❑ ❑ <br /> ❑ ❑ ❑ U &C it - /Z K ❑ ❑ ❑ <br /> 5j ❑ ❑ ❑ dile ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ ctuc ;s - /e ❑ ❑ ❑ <br /> v Jb ❑ ❑ ❑ ❑ <br /> 1( _—_>VLV� l9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4-,6 1"C ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> 831 Y_1 n e e-t ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 8 Ft( 1tA,--r7 ❑ ❑ DI DI ❑ ❑ <br /> r` r6 ❑ ❑ ❑ ❑ I ❑ I ❑ ❑ <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: — t CU <br />