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Page of_4,T_ <br /> Secondaf Containment Testing RepAR 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 applicc Conoco Phillips#255417 perator for submittal to the local regulatory agency. <br /> v <br /> 1700 East Yosemite Ave. <br /> Facility Name: Manteca, CA. 95336 Date of Testin g: j1--2 o.^rs <br /> Facility Address: N04599—SB 989 Testing <br /> Facility Contact: 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: V _ <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 /> TZ 11 11 El 0 <br /> V IN ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ' g P9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ► i ® ❑ ❑ ❑ D 1 01 ❑ ❑ <br /> �9 ® ❑ ❑ ❑ ❑ ❑ O ❑ <br /> ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> PO ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t ► g-y W ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ZI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4jo ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 10 ❑ ❑ ❑ <br /> ❑ I ❑ I ❑ I ❑ I ❑ ❑ ❑ <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: ,a , _ Date: Zo—�.y y <br />