Laserfiche WebLink
Page N of 7 <br /> k <br /> Seconda>l y Containment Testing Report Form AmFp- <br /> fi 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 proceduidt end _ <br /> printouts from tests(if applicabl 'rator for submittal to the local regulatory agency�00 <br /> BP Arco # 6347 V1r OMW:�T <br /> 2430 Joe Pombo Pkwy LTy <br /> Facility Name: Date of Testing: b� , v/C S <br /> Facility Address: Tracy, Ca 95377 <br /> SB 989 Testing <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc. <br /> Technician Conducting Test: M0Ni) &w <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 Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 7 NAWA& ❑ ❑ 7 (I)A FILL, OuCic(F ❑ ❑ ❑ <br /> I ANNIALK9 fid ❑ ❑ ❑ V1 I 0 FILL CVCKlr'f ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ V 0)a VW4 QUCKEi 10 ❑ ❑ ❑ <br /> 'IRLL some 01 ❑ ❑ ❑ �7 t D Y eta du(ici=i ❑ ❑ ❑ <br /> 912 ❑ ❑ ❑ it b-) FILE. 6uW ❑ ❑ <br /> 011- S124 ❑ ❑ ❑ 47b) 0TV4 avoftr C1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> .91 FILL Dt1CKkf 0 ❑ ❑ ❑ <br /> r4�I wE �I ❑ ❑ ❑ _3 I vW -Ncger 9 ❑ ❑ ❑ <br /> 7 a I E4 ❑ ❑ ❑ 91spek6EP VMS ❑ ❑ ❑ ❑ <br /> Iry. Sd ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 1 0 ❑ ❑ ❑ <br /> 7 5 acp mw 10 ❑ ❑ ❑ ❑ ❑ ❑ <br /> (2-) 5 rANPXq 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> i 5 t(0N,,?Wj in ❑ ❑ ❑ Its ❑ ❑ ❑ <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: Date: Q <br />