Laserfiche WebLink
f—T <br />MCB, January 2002 Page — o 0 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors ve.-YotminvDetia die testing of UST secondary containment Systems Use the <br />appropriate page Arco #02130 is tested The completed for m, wi itten test pt ocadures, and <br />pt intouftftom tet 7906 N. El Dorado St. Vity owner/operator for submittal to the local regulatory agency <br />Stockton, Ca RMATION <br />Facility Name: Nick Harvey Date of Testing: -3 <br />Facility Address # 09295 SB 989 <br />Facility Contact. Phone: -- <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rfpPese.nt during testing): <br />PT-11-11kri-TINT-UHN-F Mok <br />Company Name: <br />y Name: ornP7, <br />Wayne Perry, Inc <br />Technician Conducting Test: Alte-1Z.- 'Cc# () <br />11t <br />Credentials: )<CSLB <br />Licensed Contractor 11 SVvrRCB Licensed Tank Tester <br />License <br />icense Type- <br />A, B, 00, C21 License Number: 300345 <br />Manufacturer <br />Manufacturer Trainina <br />Component(s) Date Training.Expices <br />Furnished Upon Request <br />OMMITI-101-1 "'! 1416129*11819 �--W <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 />lechnician's Signature: ,"'/a� Date: <br />Cl/I <br />