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Page I of L <br />Secondary Containment Testing Repo t Form <br />Thisform 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 applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing: <br />Facility Address: BP/Arco #02186 <br />F 3212 N. California <br />Facility Contact: Phone: <br />Stockton, CA. 95204 <br />Date Local Agency Was 1 N04731R — SB 989 Repairs <br />Name of Local Agency Ir .4A <br />mr nmtwin 1-9-%i►rmn A 9 rl'nD ThJVnDM A TI INJ <br />Company Name: Wayne Perry Inc. <br />Technician Conducting Test: <br />Iry /V <br />Credentials: ® CSLB Licensed Contractor <br />p SWRCB Licensed Tank Tester <br />License Type: A B ASB C-10 HAZ D40 <br />Manufacturer <br />License Number: 300345 <br />Manufacturer Training <br />Component(z) Date Training Expires <br />SUPPLIED UPON REQUEST <br />a CYlX4AirADV "I 9MIZT RTCII7.TC <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:'T&&7 <br />CJ � Date: l — 3 — C) <br />r <br />nnoo <br />novo <br />0000 <br />0000 <br />0000 <br />nnoc� <br />nno■o■ <br />: <br />o00 <br />novo <br />ono■v <br />nnoo <br />nnuo <br />r�n�■■� <br />000w <br />nnr�o <br />nnni�nv <br />-------oo- <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:'T&&7 <br />CJ � Date: l — 3 — C) <br />