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E C <br /> L <br /> p, Page / of.-J, <br /> PR 4 2008 <br /> -Seaoild4ry Co' <br /> •epoft• <br /> ,;'i This form is inndedforuse.y contracrors a fonning� � '� <br /> secondarycontainment systems. Use the � <br /> appropriate pages of this form to report resultsfor all components tested.. The completed form,written test procedures,and f <br /> printoutsfrom tests(if appl,• )r/operator for submittal to the local regulatory agency. <br /> BJP.#02133.: ` . N l <br /> X908 W Senjaniiri Holt Ih --_ ----.nffl' Name: Date of Testing: 3..Z H�-,o�Stockton,Ca Address: 08103 SB989 —_ } <br /> Facility Contact: ' Phone: <br /> Date,Local Agency Was Notified of Testing: _ <br /> I.Name9f Local Agency inspector(if present during testing): NA -� <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: eek yx <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 Components) Date-1 raining Ex ires <br /> SUPPLIED UPON REQUEST <br /> 3. SiJllh[MA RY OF TEST-RESULTS~ <br /> Not Repairs _." Not Repairs <br /> Component Pass Fail Component Pass Pail Tested Made <br /> Tested Made <br /> ❑: ❑ ❑. " 1-7. -❑ ❑ ❑ <br /> . -9t ❑ ❑ ❑ r fig- ❑ ❑ ❑ <br /> 17 .4 ❑ ❑ ❑ 7-11 <br /> ❑ ❑ ❑ <br /> El ri <br /> "n ❑ ❑ ❑ e yp, ❑ ❑ i <br /> ❑ 1 ❑ 1 ❑ r p ❑ ❑ ❑ <br /> 11 El <br /> O El11 ❑ D.. ❑ ❑ i <br /> M1� l _ ❑ ❑ ❑ <br /> b� 4,Z D ❑ ❑ D ❑ ❑ ❑ <br /> 7- <br /> -if <br /> _If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> j <br /> 1 E <br /> ' 1 <br /> CER'T'IFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING f <br /> To the-best of my knowledge,the facts stated in this document are accurate and infill compliance with legal requirements . <br /> Iechnician'sSignature;.,.-. Y � Date: ,_zy 0 V- s <br />