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! <br /> ! <br /> Page of <br /> ! <br /> ! <br /> Secondary Containment Testing Report Form <br /> This form is Intendedfor,use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropi We pages of this form to report results for all components tested The completed form, written testprocedur•es, and I <br /> - -1 " -'....owner/o erator or submittal to the local re lato a en <br /> printouts from tests( p f ry g cy <br /> BP# (pQ--7C) IATION <br /> 1711 E..Yosemite Date of Testing. <br /> Facility Name: Manteca Ca <br /> Facility Address: 48102 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: IV f& A � <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 Fati Not Repairs Component Pass Fail Not Repairs ! <br /> Iested Made I Tested Made <br /> f El ❑ <br /> �. <br /> ..------ — --- --- — ---- .. -- . .._: ice.. . _.... . . p.. <br /> r _ <br /> –t~ Jo Li01 Li ! <br /> V El 0 El El <br /> � � t <br /> r' S l <br /> _. ................._ q . ... <br /> _ _ I <br /> a <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> i <br /> CERIIFICATION OF IECHNICIAN RESPONSIBLE FOR CONDUCIING THIS TESTING I <br /> To the best of my knowledge,the facts stated in Ilds document are accurate and in full compliance with legal requirements <br /> Technician's Signature: L Date: <br /> i <br />