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V <br />v <br />6Page--/— <br />e � of —7— <br />Secondary Containment TestingRe oForm <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 applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Date of <br />Facility Address: Chevron #99840 <br />Facility Contact: 4344 Waterloo Rd. Phone: <br />Date Local Agency Was Notifie Stockton, CA. 95215 <br />Name of Local Agency Inspectc N04770 — SB 989 Testing <br />2. TESTING CONTRACTOR INFORMATION <br />nrr • a #)nnA <br />Company Name: Wayne Perry Inc. <br />Technician Conducting Test:_ <br />r ' SAN JOAQUIN COUNTY <br />Credentials: ® CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester ENVI <br />License Type: A B ASB C-10 HAZ D40 <br />Manufacturer <br />License Number: 300345 <br />Manufacturer Trainine <br />Component(s) Date Training Expires <br />SUPPLIED UPON REQUEST <br />3_ SITIMiMARY OF TF,ST RF,SITi.TS <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: Date: <br />I I I oil) I I;d It <br />3 <br />G <br />; <br />DDD <br />000 <br />• <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: Date: <br />