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Pa � If Z �S <br /> Seconda Containment Testing Rep Form `� C <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment syyt°erhs. 7I G U <br /> appropriate pages of this form to report results for all components tested. The completed form, writt� ocedures,and <br /> printouts from tests(if applicably rator for submittal to th hT' "of y. <br /> BP Arco # 6347 MiTISE'VI-* <br /> 2430 Joe Pombo Pkwy <br /> Facility Name: Tracy, Ca 95377 Date of Testing: <br /> Facility Address: SB 189 ftapag <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: /e , <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 /> L= <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> - ❑ ❑ M- ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> [111ij ❑ 1 ❑ 1 10111 ❑ 1 ❑ <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: _ zzr 2 J-0-5- <br />