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Page i of <br /> Secondary Containment Testing Report Form ii <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use f&N, � . 2005 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test proceduresE T HEALTH <br /> printouts from tests(if applicable, Chevron-209167 storforsubmittal to the local regvICEs <br /> 1234 Yosemite Avenue <br /> P <br /> Facility Name: Manteca, CA 95336 Date of Testing: - J <br /> Facility Address: N05295-S989 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: 616C <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 /> / 5 ❑ ❑ ❑ ❑ ❑ Ej ❑ <br /> e' EN ❑ ❑ ❑ ❑ ❑ ❑ D <br /> 14 ❑ ❑ ❑ ❑ ❑ ❑ <br /> fid ❑ ❑ D E7 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> r" / ❑ ❑ ❑ ❑ O ❑ ❑ <br /> .07 '// ❑ ❑ ❑ El —b ❑ ❑ <br /> ?7 444 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ER ❑ CJ_ ❑ ❑ ❑ ❑ ❑ <br /> PL ❑ ❑ ❑ ❑ D ❑ ❑ <br /> 54CZ IAC ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If aensc-A ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El 0 <br /> 0 El <br /> B ❑ ❑ O ❑ ❑ ❑ ❑ <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: ate: -1r <br />