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SWRCB,January 2002 Page /of <br /> Secondary Containment Testing 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 tes; 'lily owner/operator for submittal to the local regulatory agency. <br /> Chevron#9-6171 <br /> TION <br /> 6633 Pacific Ave. Date of Testing: 3 i i- i � <br /> UWA <br /> Facility Name: Stockton,Ca 95207 <br /> Facility Address SB 989 Nick Harvey <br /> Facility Contact: #11061 Phone: <br /> Date Local Agency Was Notified of Testing: 2-13 -it <br /> Name of Local Agency Inspector(ifpresert during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test: ICC# 5.115'7.-7g- <br /> Credentials: <br /> - <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,c 10,C21/D40 Haz License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Comonent(s) Date TrainingExpires <br /> Furnished Upon Request <br /> i <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested Repairs <br /> Component Pass Fail Tested Made <br /> -7-1 ®. ❑ ❑ ❑ aft "I ❑ ❑ ❑ <br /> € t 7 -Z ❑ ❑ ❑ r e /0-/Z- ❑ ❑ ❑ <br /> 0 El El <br /> it1 � ❑ 11 a ' ❑ El El <br /> ❑ ❑ ❑ r nn ❑ ❑ ❑ <br /> cc l ❑ ❑ ❑ ' / Z ❑ ❑ ❑ <br /> ® ❑ O-j ❑ ' ° l 1g ❑ ❑ ❑ <br /> c 7- N ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> i <br /> CERTIFICATION OF TEC CLAN RESPONSIBLE FOR CONDUCTING TI1IS TESTING <br /> To the best of any knowledge,the facts stated in this document are accurate and in full coanpliance with legal requirements <br /> Technician's Signature: Date:',� � `,c-air <br /> / <br />