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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report For <br /> This form is intended for use by contractors petformingperzodic testing of UST seeondaty eontainmentsystems Use the <br /> appropriate pages of'th_is form to report results for all components tested The completedfotttt,written testprocedures, and <br /> printouts from tesis({ Chevron 020-1761. owner/operator for submittal to the local regutalmy agency. <br /> 1103 S.Main St: [AXION <br /> Facility Name: Manteca,Ca 95337 Date ofTesting: <br /> Facility Address: Nick Harvey, <br /> Facility Contact: #N12393 SB 989 phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test.-__ ll e,,A hlflepz ICC# -//S- 7,7 b" <br /> Credentials: 11 CSLB Licensed Contractor 11 SWRCB Licensed Tank Tester <br /> License Type: A,B,e10,C21/D40 Ilaz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expixes <br /> Furnished U on Request <br /> 3. SUMi Y OF TEST RESUL'T'S _ <br /> Component Pass Fail '',Not Repairs Component )Pass Fail Not Repairs <br /> Tested Made Tested Matte <br /> V7-1 K ❑ ❑ ❑ © ❑ ❑ ❑ <br /> t( T2 On ❑ ❑ ❑ !i //-l• Q ❑ ❑ <br /> x ter• C9 ❑ ❑ ❑ t7-7 ❑ ® ❑ ❑ <br /> f t; <br /> 7-1, ❑ ❑ ` y 1 �l ❑ a <br /> �� z1 ❑ ❑ ❑ P, T7 z ® ❑ ❑ ❑ <br /> 9/ JM ❑ ❑ ❑ 57/ M ❑ ❑ 1 ❑ <br /> ,r S_y ❑ Q 0 3P -z ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion oftests: <br /> CERTIFICATTDN OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of arty lrnotvledge,the facts stated in this docuutent rare accurate and 111fill compliance Wth legal requirements <br /> Technician's Signature: 'Al—) Date: 12 - Y— 17- <br />