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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 tests Chevron # 208117 v owner/operator for submittal to the local regulatory agency. <br />755 S Tracy Blvd VIATION <br />Facility Name: Tracy, Ca Date of Testing: 7 _may <br />Facility Address: 08128 SB989 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): NA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry Inc. <br />Technician Conducting Test: ' ✓ <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 SULTS <br />component <br />COMM; <br />Baum <br />M" <br />M W <br />m <br />mm�j <br />oau� <br />�wv <br />ww <br />ON <br />Caoov <br />mmoo, <br />:,moo <br />uovo <br />ouv <br />woos <br />©®vo; <br />Lai <br />oro"I <br />Lvov <br />ouov <br />WAR/ <br />�:a`i <br />oo; <br />mum <br />m <br />T u <br />-001-- <br />-- --- - muma <br />o' <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 frill compliance with legal requirements <br />Technician's Signature: Date: ,�o r v— <br />