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T 1 <br /> I <br /> Page !j of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic testing of.UST secondary containment systems Tse the <br /> appropriate pages of this foam to report results for all components tested The completedforsn,written test procedures;and <br /> printouts f om tests y owner/operator for submittal to the local regulatory agency <br /> bhevr•on 9 96171 <br /> 5)633 Pacific Ave MATION <br /> Facility Name: `toekton,Ca Date of Testing: <br /> Facility Address: r 8055 SB989 <br /> Facility ontact: Phone: i <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): NA <br /> - i <br /> t <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: L:Y <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 Iiainin Ex ices <br /> SUPPLIED UPON REQUEST i <br /> i <br /> 3. SUMMARY OF TEST RESULTS <br /> Component ]'ass Fail Not Repairs Component Pass Fail Not Repairs ; <br /> Tested Made bested Made <br /> 7-1 aR d / 0- <br /> 7- z 9 11?t L1 I ❑ ❑ <br /> r. ❑ j., j F <br /> Zl El11 ❑ p/ ❑ <br /> rr ¢/ �I. ❑ V ❑ <br /> 1.3 Ll ❑ S''5) ❑ i <br /> El <br /> a� .. ❑ _ ❑ ❑ ❑ ❑ f <br /> r r ----- A ® ---- ❑ ❑ ❑ <br /> V9 ❑ ___ ❑ © ❑ 8 <br /> y _ ®— <br /> MEEI <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 1 <br /> f <br /> f <br /> CERTIFICATION OF IECHNICIAN RESPONSIBLE FOR CONDUCIING THIS TESTING 4 I <br /> To the best of nsy hnowtedge,the facts stated in this document are accurate and in full compliance with legal requirernents <br /> Technician's Signature: °`''�'u c` Date: -51.. 71 0 <br /> i <br />