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� 5 <br /> Page of <br /> . t <br /> Secondary Containment. esting 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 weer/operator for submittal to the local regulatory agency. <br /> Chevron #209167. ATION <br /> - 1234 Yosemite Ave <br /> Facility Name: Date of Testing: _/50 Ir <br /> Facility Address: Manteca, Ca <br /> Facility Contact: 8057 SB989 Phone: j <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rfpresent during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION i. <br /> '.Company Name: Wayne Perry inc. <br /> Technician Conducting Test: ,,el< :4 J <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester 3 <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 /> 7 El ❑. ❑ ❑ ❑ ❑ <br /> r , gl ❑ ❑ ❑ ❑. El 0 ❑ <br /> "Zk El <br /> IN ❑ ❑ ❑ ❑ <br /> rr ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> o, -1 ® ❑ ❑ ❑ ❑ ❑ ❑ 1q: <br /> 9l® 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ . I <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El <br /> T q/ a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If - <br /> `>If hydrostatic testing was performed,describe what vas done with the water after completion of tests: j <br /> i <br /> i <br /> 1 <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 i <br /> Technician's Signature: �) J Date: S- <br /> ell, <br /> f I° <br /> I <br /> 1 <br />