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Page I of 4 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systerns. Use the <br />appropriate pages of this form to report results far all components tested. The completed form, written test procedures, and <br />printouts from tests ffapplicable), should be prod d t the facility ownerloperator for submittal to the local regulatory agency, <br />a; ; <br />1. FACIL INFORMATION <br />Facility Name: CHEVRON 4210997 Elie ofTesting: 10115/2012 <br />Facility Address: 1442A COLONY DR / JACK TONE RD. RIPON, CA 95366 <br />Facility Contact: Phone, <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector, (ifpresent during testing): <br />2. TESTING CONTRACTOR LNIFORMATION <br />Company Name: Wayne Perry, lncorported <br />Technician Conducting Test: Nick Harvey ICC #5115738 <br />Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A, HAZ, C21, C10, B, C61, D40 I License Number., 300345 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Furnished on r uest <br />Component <br />91 Prod Secondu <br />... ....... .. <br />■ <br />91 Fill Bucket <br />■ <br />to <br />■0 <br />............ <br />-UNE <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />One 1) 55 -gallon drum was left on site <br />CFRTIFICATION OF TECHN'ICI.ANRESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of iny knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:_—L� Date: -10/15/2012 <br />