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ar Containment Testing Report- ,rm Ie <br /> Secondary containment systems. Use the <br /> This vrni is intended for toe by contractors performing periodic testing of'UST'secondary <br /> f owner/o eratorfor•submittal to the local regulatory agency.. <br /> o this form to report results for all components <br /> tested Thi completed form,written test procedures,and <br /> appropriate pages f hcable), should be provided to the facrl ty <br /> pri�riouts front tests(if app � <br /> : 1.. FACILITY INFORMATION Date f Teing:o _� <br /> " Z j o <br /> gp-Vr0607-0Facility Name <br /> Facility Address: f 17// <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing: ��NA <br /> Name of Local Agency Inspector(ifpjgsent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Naive: Wayne Perry Inc. <br /> Technician Conducting Test: /i�l ,� ❑SWRCB Licensed Tank Testei <br /> Credentials: ®CSLB Licensed Contractor License Number:300345 <br /> License Type: A S ASS C-10 HAZ D40 ✓ <br /> Manufacturer Trainine Date Irainin�Expires <br /> Com onent s <br /> Manufacturer �� <br /> SUPPLIED UPON REQUEST <br /> _ .r <br /> RY.OF TEST RESULTS_ Not Repairs <br /> 3. SUMMA Component <br /> Not Repairs Tested <br /> Component Pass Fad Tested Made ` ❑pass Fail T❑ed M❑ <br /> D El El CY ❑ ° <br /> J1Li Lj 13 <br /> El <br /> El <br /> El J- <br /> El 11 0El El <br /> e El ❑ arc' L-•- ❑- ❑ ❑ <br /> iJ ❑ ❑ ❑ �r ! ❑, ❑ ❑ ❑ <br /> t� i- ❑ ❑' ° ° <br /> El -d ° ° <br /> " 7_ ❑ D' ❑ ❑ —�— ❑ ❑ ❑ ❑ <br /> r 4 ��. ❑ L�' ❑ ❑ __ ❑ ❑ ❑ El _ <br /> El El <br /> th the water after,completion of tests: <br /> If hydrostatic testing was performed;describe what was done wi —� <br /> rurnent are accurate and in full compliance with legal requirQlnertis <br /> CERTIFICATION OF'IECHNICIA do �pONgIBLE FOR CONDUCTING THIS TESTIN <br /> To the best of my knowledge,the facts stated in this <br /> Date: <br /> I echnician's Signature:Z, f �t.LL•� <br /> TLe_ <br />