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May, 1. 2014 8:57AM No, 4085 P. 3 Page 2 of 26 Secondary Containment Testing Report Form This form is intendedfor use by contractors perfor•»ring pe►°iodic testing of UST secondary containment systems. Use the appropriatepages ofthisfonn to report rwsultsfor all components tested. The completedform, written testprocedures, and printoutsfrom tests (_�^--�-"--r ,Chevron #307709 )' owner/operatorfor submittal to the local regulatory agency. 10858 Trinity Parkway UORMATION Facility Name: Stockton, CA Date of Testing: -7 7 _ I ,IR/ Facility Address: Jason Smith l Facility Contact: 013625 Saw Work Phone: Date Local Agency Was Notified of Testing: Name of Local ARencv Inspector Opresent durinz testinz): 2. TFSTING CONTRACTOR INFORMATION Company Name: 'Wayne Perry, Incorporated Technician Conducting Tess: Technician Name & Sery Tech #Aezek 4699 ViF 3 Credentials: X. CSLP Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, HAZ, C21 License Number. 300345 Manufacturer Training Manufacturer Com nent s Furnished on request 3. SUMMARY OF TEST RESULTS ENVIRONMENTAL HEALTH If hydrostatic testing was performed, describe what Was done With the water after completion of tests: CERTIFICATION OF TECHNICIAN RFSPONSMLF FOR CONDUCTING THIS TESTING To the best of my knowledge, the f is stared in this document are accurate and in full compliance with legal requirements Technician's Signature: Date)-jy ML .. - luuuuL■JL■JMOIR- 117111o■o MW MEM .. �1 w■ ■m0■ X000■ f.� w■ ■00■ mm mm L7m ■00■ MIM MM 0■ mw mm I �■0■0■ 0 u"■u u�uu oo■v IfflimoNI as■o 0000; 0000: 0000 0000_._ _ ---- ao�■� If hydrostatic testing was performed, describe what Was done With the water after completion of tests: CERTIFICATION OF TECHNICIAN RFSPONSMLF FOR CONDUCTING THIS TESTING To the best of my knowledge, the f is stared in this document are accurate and in full compliance with legal requirements Technician's Signature: Date)-jy