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Page I of 7 <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 tests (if applicahlo ) .chnuld he nrovided to the facility owner/operator for submittal to the local regulatory agency. <br />BP/Arco #05450 N <br />Facility Name: 1617 W Fremont Date of Testing: 7-13-04 <br />Facility Address: Stockton, CA. 95203 <br />Facility Contact. N04732 — SB 989 Testing Phone: It <br />% (,) 66A- & <br />Date Local Agency Was Notinea of i esuii% . y <br />Name of Local Agency Inspector (if present during testing): NA <br />7_ WNTING f'ONTRACTOR INFORMATION A/0 <br />Company Name: Wayne Perry Inc. <br />U, <br />Technician Conducting Test: <br />Not <br />Tested <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Ta <br />ster O <br />License Type: A B ASB C-10 HAZ D40 License Number: 300345 ,o <br />Manufacturer Trainine <br />Manufacturer Component(s) <br />O <br />�%�,✓Tf <br />F Training Expires <br />SUPPLIED UPON REQUEST <br />F �S <br />R 113E S1jvWP <br />❑ <br />0 <br />87.O CtI N D A f+ <br />4 IN <br />-I- SITMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />R 113E S1jvWP <br />❑ <br />❑ <br />87.O CtI N D A f+ <br />4 IN <br />❑ <br />❑ <br />❑ <br />97-54,P1400 f-wU nA: <br />❑ <br />IN <br />❑ <br />❑ <br />S7t.Slj%vh4 it ► t M <br />4 <br />❑ <br />❑ <br />❑ <br />q 1 Toap,N IE StjM <br />❑ <br />❑ <br />❑ <br />fA0Dvf-TSr-0J0#AFf E.PJCsM <br />❑ <br />❑ <br />❑ <br />- 1►'1 Fi 11 <br />❑ <br />❑ <br />❑ <br />91iv F"v%RE ToA Fa set.e. <br />i- <br />❑ <br />❑ <br />❑ <br />• SIPA00 F►t) suv4p <br />❑ <br />❑ <br />❑ <br />.M r.JK AvNJl.atz <br />9 <br />❑ <br />❑ <br />❑ <br />q 1) JM <br />❑ <br />❑ <br />❑ <br />51PAaP ;ArrK AnWVLA <br />1) <br />❑ <br />❑ <br />❑ <br />7•rot au v,� <br />❑ <br />❑ <br />❑ <br />91 T-AO,o+agl LAfZ <br />FRI <br />❑ <br />❑ <br />❑ <br />ql Fill 6Jc1L -r <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />VAMP- b K T <br />i•2- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />t , ►, <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />vo <br />» <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />J.p <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />VOC -b <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />U0(_ -$ <br />❑ <br />❑ <br />❑ <br />1 <br />❑ <br />❑ <br />❑ <br />❑ <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 />Technician's Signature: 0�9z 4/-/- — Date: 7— 13 — 0`/ <br />