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Page _ I of Secondar, _"ontainmeat Testing Repoll .. Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicc BP Arco # 05469 Aerator for submittal to the local regulatory agency. 130 S. Wilson Way Facility Name: Date of Testin Facility Address: Stockton CA 95205 g Facility Contact: N05245 -SB 989 Testing Phone: Date Local Agency Was Notified of Testing : Name of Local Agency Inspector (if present during testing): NA D V Lg LO 2. TESTING CONTRACTOR INFORMATION Company Name: Gyne Perry Inc. 5 Technician Conducting Test: &ft V p SAN J Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Teste ARONMENTAL HEALTH npn License Type: A B ASB C-10 HAZ D40 Manufacturer License Number: 300345 Manufacturer Training Component(s) Date Training Expires SUPPLIED UPON REQUEST M 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 5,—/ 3 —0-r 2 T3 cop R2002.1 - ray po M 0©� INFE - ._ - + - 00�� W0� mmm� mm�'' m If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 5,—/ 3 —0-r 2 T3