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Mar, 19. 2014 10:13AM No, 3963 P. 7 <br />Page 2 of 14 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing peHodic testing of UST-Fecondary containment systems. Use the <br />appropriate Pages o-fthis-form to report results for all components tested, The completed fo"n,written test procedures, and <br />printouisfrom tests (ifapplicable), should beprovided to thefacility ommei-loperatorfor submittal to the local regulatory agency. <br />UIMYWOIt <br />Facility Name: rZ/ c <br />q— e of Testing: jr <br />Facility Address: .3,yjf It) eW <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector 60resent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry, Incorporated <br />Technician Conducting Test: Technician Name & Sery Tech # &ekA�,o <br />Credentials: X CSLIB Licensed Contractor 0 SWRCB Licensed Took Tester <br />I License Type: A, HAZ, C21 Lice= Number: 300345 <br />MMMMMMMMMM� <br />MaLlfacturg Train'n <br />Manufacturer Coznponew(s) R E <br />Furnished on regumt <br />MAR 19 2014 <br />ENVIRONMENTAL HEAL] <br />7MT97-.V1-v;.Tr-_ M, <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 stared in this document are accurate and in full compliance with legal requiremenn <br />Technician's Signature: E Date:— /,ov <br />z <br />