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Page 1 of 9 <br />Corrected Summary Page -secondary Containment Teen Report Form <br />Y � p <br />This form 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. FACELITY INFORMATION <br />Facility Name: CHEVRON #210997 Date of Testing: 8/14/2012 <br />Facility Address: I442A COLONY DR I JACK TONE RD, RIPON, CA 95366 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : 8/7/2012 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Predentials: <br />y Name: Wayne Perry, Incorporated - - - -- - - - <br />an Conducting Test: Nick Harvey ICC #5115738 <br />X CSLB Licensed Contractor SWRCB Licensed Tank gTester <br />ype: AHAZ, C21, C10, B, C61, D40 License Number: 300345 <br />Manufacturer "Training <br />nufacturer Components) HTraining <br />Furnished on request <br />3. SUMMARY OF TEST RESULTS <br />Cam onent <br />P <br />Pass Fail <br />Not Repairs <br />Tested Made <br />Component <br />Pass <br />Nat Repairs <br />Fail Tested Made <br />87 Annular <br />E ❑ <br />❑ <br />❑ <br />UDC 11/12 <br />® <br />❑ ❑ <br />❑ <br />91 Annular <br />E ❑ <br />❑ <br />❑ <br />87 Fill Sump <br />Z <br />1:11 ❑ <br />❑ <br />Prod Secondary Line <br />❑ <br />❑ <br />' [] <br />91 Fill Sump <br />❑ ❑ <br />t87 <br />9lPrad Secondary Line <br />❑ <br />❑ <br />87 Fill Bucket <br />❑ <br />® ❑ <br />❑ <br />87 Vent Secondary Line <br />Z ❑ <br />❑ ❑ <br />91 Fill Bucket <br />[] <br />❑ <br />❑ <br />91 Vent Secondary Line <br />❑ <br />❑ <br />❑ <br />87 Vapor Bucket <br />0. <br />7=71 <br />Vapor Return Secondary Line <br />E ❑ 1 <br />❑ ❑ <br />91 Vapor Bucket <br />® <br />❑ ElEl87 <br />STP Sump <br />❑ <br />❑ <br />1:1❑ <br />❑ ❑ <br />EJ <br />91 STP Sum <br />❑ ❑ <br />❑ <br />❑ 10:1 <br />El <br />UDC❑ <br />❑ <br />❑ <br />EEI <br />❑ ❑ <br />UDC 3/4 <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />UDC7/8 <br />Li <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC7/8 <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />UDC 9110 <br />[] <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <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 />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: OL�'7 Date: -8/14/2012— <br />