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t Page(of- SecondaNy Containment Testing Repdet Form O�I`I`^�+-J(�� M This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use t r/e#FED appropriate pages of this form to report results for all components tested. The completed form, written test proko re d printouts from tests(if applicab: srator for submittal to the local regular r70 Chevron#98264 E�RONMEH Facilit Name: 3775 N. Tracey Blvd. Facility — Facility Address: y Trace , CA 95376 Date of Testing: _�s_L ERVInF Facility Contact: N05207-SB 989 Testing Phone: Date Local Agency Was Notified of Testing : Name of Local Agency Inspector(if present during testing): NA 2. TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry Inc. Technician Conducting Test: Alck #4glley, Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A B ASB C-10 HAZ D40 License Number: 300345 Manufacturer Trainine Manufacturer Component(s) Date Training F fres SUPPLIED UPON REQUEST 3. SUMMARY OF TEST RESULTS Com nent Pass Fail Not Repairs Com Not Repairs po Tested Made ponent Pass Fail Tested Made u LA 00 ❑ ❑ ❑ PILL A7P T7 X ❑ ❑ ❑ M ❑ ❑ ❑ , , to ❑ ❑ ❑ „ qj m ❑ ❑ ❑ cl I RL ❑ ❑ ❑ PIPE =eVNO4RY 17 M ❑ ❑ ❑ FILL ® ❑ ❑ ❑ t ❑ ❑ ❑ „ ® ❑ ❑ ❑ pipe aM P IVA"FOR G ct ET T7 IN ❑ 1 ❑ ❑ „ m ❑ ❑ ❑ „ ® 01 ❑ 1 ❑ If 91 m ❑ ❑ ❑ „ q ® ❑ ❑ ❑ AC 1-1 $1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ •� ® El ❑ ❑ 11 ❑ 17 Ei ❑ El ❑ ❑ ❑ 11„ 4110 19 ❑ ❑ ❑ ❑ ❑ ❑ ❑ t' il-1a ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ 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: