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Page i 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(if applic 'operator for submittal t2M J�1 �3u4 urv+ey ?It <br /> Arco # 06080 f�I�T" J� G// <br /> ►N <br /> Facility Name: 85 E. Louise Avenue Date of Testing:` <br /> Facility Address: Latluop, CA 95330 HEALTH DEPARTMENT <br /> Facility Contact: N05115- SB 989 Testing Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. _ <br /> Technician Conducting Test: A, ek .4 c <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 /> ® ❑ ❑ ❑ / ® ❑ ❑ ❑ <br /> 191 ❑ ❑ ❑ ,,t 13,oee ® ❑ ❑ ❑ <br /> M ❑ ❑ ❑ - ® ❑ ❑ ❑ <br /> R7 ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ v� ,,mak -- -r7 N ❑ ❑ ❑ <br /> T2 ® ❑ ❑ ❑ y j-'9 W ❑ ❑ ❑ <br /> CO ❑ ❑ ❑ $ ® ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> yAPc- mti R El [10 - ❑ ❑ ❑ El,r - h N ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> De i - z ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> W ❑ ❑ ❑ — ❑ ❑ ❑ ❑ <br /> M ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> 7_-1 E& ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> IL I- r7 to ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: f( i Date: ,z 0 —ns <br />