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�I <br />SecondalgContainment Testing Repdo Form p4y <br />This form is intended for use by contractors performing periodic testing of UST secondary containment sys s. Use t e 9 2005 <br />appropriate pages of thisform to report results for all components tested. The completed form, written test p <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the loc 0cj1,Qy ,� r� <br />1. FACILITY INFORMATION ��CC ICES <br />Facility Name: Chevron -208117 Date of Testing: 4 , z <br />Facility Address: 755 S. Tracy Blvd. <br />Facility Contact: Tracy, CA 95376 Phone: <br />Date Local Agency Was Noi N05204-SB989 Testing <br />Name of Local Agency Insp-- <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry Inc. <br />Technician Conducting Test: AlleA #,,I 7 j/.-`' <br />Credentials: <br />/t``'Credentials: N 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 />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: % <j Date: ,�,_ t z• <br />Flow <br />00©� <br />000 <br />0___m <br />"N <br />i <br />MM <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: % <j Date: ,�,_ t z• <br />