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I <br /> MAR 2 6 2008 pabe— Of� <br /> Secondary Containment <br /> This form is intended for use by contractors performing periodic &ntainment systems.. Use the <br /> appropriate pager of this form to report results for all components tested. The completed form,written test procedures,and <br /> printouts from tests(if applica aerator for submittal to the local regulatory agency. <br /> BP 4 05080 <br /> ---85 E.Louise Ave fj <br /> Facility Name: Data of Testing: -a 1 _ a I <br /> Lathrop, Ca <br /> Facility Address: 04475 SB989 <br /> Facility Contact:..... 1.1. Phone: f <br /> Date Local Agency Was Notified of Testing:. <br /> Name of Local Agency Inspector(if present during testing): NA <br /> I <br /> 2. TESTING CONTRACTOR INFORMATION j <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: N 14# 144 hV <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB 0-10 HAZ D40 License Number:300345 <br /> Manufacturer Trainins= <br /> Manufacturer _ Component(s) _ Date 1i aining Expires <br /> SUPPLIED UPON REQUEST — <br /> i <br /> 3. SUMMARY OF TEST RESULTS _ <br /> Not Repairs Not Repairs <br /> Component Pass Fail Iested I Made Component Pass Fail Tested Made <br /> ❑ ❑ ❑ P I ❑ ❑ ❑ <br /> 1 <br /> �a�t. S 7 L9' ❑ ❑ ❑ g 7 ❑ D ❑ <br /> s► ra- ❑ ❑ ❑ �, —� O ❑ ❑ <br /> rcam. <br /> 2-1 ❑ ❑ 1 ❑ ,, — ❑ ❑ El <br /> ❑ ❑ ❑ ❑ ❑ <br /> - . ❑ ❑ ❑ Rovr 1 - ❑ ❑ ❑ <br /> u e- — r ❑ I D ❑ ,c� 1-�.v s�� C�- ❑ ❑ ❑ j <br /> � - 3-�l Ci ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> • ;-G C ❑ I ❑ 1 ❑ -- ❑ ❑ ❑ ❑ <br /> y �0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Y. Gg'y 1J ❑ ❑ ❑ ❑ ❑. ❑ ❑ I <br /> 4! CrX ❑ ❑ ❑ ❑ ❑ D ❑ j <br /> ❑ ❑ ❑ I ❑ ❑ ❑ <br /> I - ❑ ❑ ❑ D ❑ ❑ ❑ <br /> .� <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> � I <br /> I <br /> f <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:e' U c Date: �7—,I <br />