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IAF 0 - ) o� � <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors petfonning periodic testing of UST secondary containment systents. Use the <br /> appropriate pages of this form to report results for all components Jested The completed fortn, written test procedures and <br /> P1 intouts front tests (if r Arco#02093 finer/operator for submittal to the local regulator),n,�t r v. <br /> 3425 Tracy BIvd. :TION <br /> Facility Name: Tracy,Ca 95376 _s Date of Testing: �/_j-z.y� <br /> Facility Address: Nick Harvey - <br /> Facility Contact 09143 SB 989 _ — [Phone. <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): NA <br /> � <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: _Wayne Perry Inc. <br /> oTech.nducting;nician CoTest: /e� Lr�y ; 7F /-os% <br /> 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Tralnine <br /> Manufacturer _ Component(s) _ Date TrainingEsxpires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component p Rai, Not Repairs Component p Fail Not Repairs <br /> _ Iested Made Rested Made <br /> El <br /> E4— <br /> -1 -0-1 ❑ ❑ = <br /> _.. ® ❑ ® ❑ <br /> 1: 9/ . M ❑ ❑ ❑ F • , ❑ El ❑ <br /> El <br /> El <br /> 0 11 <br /> u c j� 'z Ql <br /> T' ❑ ❑ ❑❑ ❑ ❑ � <br /> ❑ ❑ ❑ ❑ <br /> _ D D ❑ O <br /> _ _A11101 ❑ 1 ❑ _— - ❑ 01 ❑ <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 /> I echnician's Signature: Date: 7- ,j Y <br /> 4 7 __ <br />