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Secondary Containment Testing Report Form JUL 20 20118 This form is intended for use by contractors performing periodic testing of UST secondary containment syste %If ftEA ENTAL appropriate pages of this form to report results for all components tested The completed form, written teft��fvP�TQ�AENT printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the lova regulatory agency. FACILITY INFORMATION Facility Name: Chevron 210997 Date of Testing: 06/20/2018 Facility Address: 1442 W. Colony Rd, Ripon, CA 95366 Facility Contact: Phone ❑ Initial ❑ Repair Test Date Local Agency Was Notified of Testing: 06/07/2018 ❑ 6 Month ❑Other Name of Local Agency Inspector (if presen/ during /wring): none M Triennial License Number: 300345 TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry Inc Pass Technician Conducting Test: Nick Harvey ICC# 5115738 Credentials: R1 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester I p ICC UST Service Technician License Type: A C21 C10 B C61/D40 HAZ C34 License Number: 300345 Manufacturer Manufacturer Training Component(s)) Date Training Expires FURNISHED UPON REQUEST Rl ❑ ❑ ❑ UDC 7/8 ✓❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Tested Not Repairs Made Component Pass Fail Not Tested Repairs Made 87 Annular Rl ❑ ❑ ❑ UDC 7/8 ✓❑ ❑ ❑ ❑ 91 Annular © ❑ ❑ ❑ UDC 9/10 IZI ❑ ❑ ❑ 87 Prod Sec Line [21 ❑ ❑ ❑ UDC 11/12 IZI ❑ ❑ ❑ 91 Prod Sec Line © ❑ ❑ © 87 Fill Sump IZI ❑ ❑ ❑ 87 Vent Sec Line ❑✓ ❑ ❑ ❑ 91 Fill Sump El ❑ ❑ ❑ 91 Vent Sec Line © ❑ ❑ ❑ 87 Fill Bucket El ❑ ❑ ❑ Vapor Return Sec Line © ❑ ❑ ❑ 91 Fill Bucket ✓❑ ❑ ❑ ❑ 87 STP Sump © ❑ ❑ ❑ 87 Vapor Bucket 171 ❑ ❑ ❑ 91 STP Sump © ❑ ❑ ❑ 91 Vapor Bucket ❑✓ ❑ ❑ El UDC 1/2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 3/4 © ❑ El ❑ ❑ ❑ ❑ ❑ UDC 5/6 © ❑ ❑ r-1-1 ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: No drums were left on site. For any equipment capable of generating a print out of test results, you must attach a copy of the test report to this certification ❑ System printout attached. 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: 06/20/2018 r�i