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Feb. 2 2015 1 : 03PM No, 5151 P. 3 <br /> S'WRC)3,January 2002 Wage 1 of <br /> Secondary Containment Testing Report Form <br /> This form is Intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriatepages of thisfalm to reportresultsfor all components tested. The completedforn,written testprocedures, and <br /> printouts from tests jfapplicable),should be provided to the facility owner/operator for submittal to the'local regulatory agency. <br /> 1. F.A.CILITY INFORMATION <br /> Facility Name: d' 6) 916 2 1 Date of Testing: Z—1 --f S <br /> Facility Address: 1 z 3 <br /> Facility Contact: Phone: A E 1:1 <br /> Date Local Agency Was Notified of Testing: a i 5,1 1S <br /> Name of Local Agency Inspector(if present during testing): 119 2 3 2015 , <br /> Z. TESTING CONTRACTOR INFORbL4,TION <br /> CoinpanyName: 'W'aynoPerry,Inc WUA1-UnC0AffnACWrr <br /> Technician Conducting Test: N/C�k ,q r`; ICC# ��S 7�f <br /> Credentials: 0 CSLB Licensed Contractor ❑S'WRC13 Licensed Tank Tester <br /> License Type: A,B,c10,C21/D40 Haz License Number: 300345 <br /> Manufacturer Tralninp_ <br /> Manufacturer Component(s)) Date 7Yaining Expires <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested I Made <br /> y R1 ❑ ❑ ❑ 0 D 0 D <br /> 91 D3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t` S Sf 7 ill ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> rteji ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ D ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0' 0 ❑ D ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ 0 ❑ ❑ ❑ ❑ D 0 <br /> 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ D ❑ ❑ - ❑ <br /> 0 1 D ❑ ❑ ❑ ❑ 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water alter completion of tests: <br /> CERTIFICATION OF TEC CYAN RESPONSIIBI.,1E VOR CONDUCTING TIUS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in f X compliance with legal requirements <br /> Technician's Signatare: Date: <br /> Received Time Feb. 23. 2015 1 : 13PM No. 8187 <br />