Laserfiche WebLink
Page ! of 2— <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 applicable),should be provided to the facili o fit /o ra 's ittal to the local regulatory agency. <br /> 1. FACILITY INFO TION <br /> Tm- <br /> Facility Name: Sot)())3�` � esting: � — 7-0 <br /> Facility Address: <br /> Chevron -#201761 F`' �l� E <br /> tfE� -� rpl. <br /> Facility Contact: 1103 S Main Street Phone: <br /> Date Local Agency Was Notii Manteca, CA. 95337-5743 <br /> Name of Local Agency Inspec N04884R—SB989 Repairs <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: J'z_F F FL)n)K- <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Trainine <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 /> S e c e�j ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 11 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 01 ❑ <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: —zo— S <br />