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Page 1 of 4 -Secondary Containment Testing Report 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 applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON #210997 1 Date of Testing: 10/15/2012 Facility Address: 1442A COLONY DR / JACK TONE RD, RIPON, CA 95366 Facility Contact: Phone: Date Local Agency Was Notified of Testing : Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry, Incorporated Technician Conducting Test: Nick Harvey ICC #5115738 Credentials: X CSLB Licensed Contractor 11 SWRC13 Licensed Tank Tester License Type: A, HAZ, C21, C10, B, C61, D40 License Number: 300345 Manufacturer Training Manufacturer Component(s) Date Training Expires Furnished on request I SUMMARY OF TEST RESULTS Component FMMI 91 Prod • i . 87 Fill Bucket 10101 IN M M 0 Elm 91 Fill Bucket C■p ■00 �■ �■ ■OD i- C■■�■ pp �L7�■ �7■ CDDD []■ �■ ate■ Com■ ■0�■ �L�A■ ■0 _ CD®�7■ LSO■ ■0 CD�a■ ©■ �0 ■0 C©Q�7■ DDD ■Q 1 i' hydrostatic testing was performed, describe what was done with the water after completion of tests: One (1) 55 -gallon drum was left on site 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: -10/1512012