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Aug. 28. 201410: 14AM No. 4580 P. 3 <br /> Page 2 of 26 <br /> Secondary Containment Testing Report For <br /> This fotzn is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages o fthis fora:to report results for all components tested. The completed farm, writren rest procedures,and <br /> printouts from tesr.' Chevron 499$40 Wy ownet/operatorfor submittal to the local regulatory agency. <br /> 4344 Watery Road ITTF TION <br /> Facility Name: Stockton,CA Date of Testing: 7- '3- 1 y <br /> ]Facility Address: Jason Smith <br /> Facility Contact: .._. #N'13650 Saw Work Phone: <br /> Date Local Agency Was Notified of Testing. <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inco orated <br /> Technician Conducting Test: Technician Name&Seri+Tech# 1K ,� 1,11!r , - <br /> Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A,ELA7,C21 License Number:300345 <br /> Manufacturer Trah&z <br /> Manufacturer Co nent s Date Training Ex ices <br /> Furnished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fall Not Ropairs <br /> Tested Made Tested Made <br /> ❑ ❑ ❑ <br /> 121 <br /> ElElEl <br /> y01 1 R I I ❑ ❑ <br /> �,'7 ❑l FE 11El <br /> !P ❑ <br /> 1:1 Ej <br /> Ti <br /> El <br /> El El 1:1El❑ F1F] ® ❑. ❑ <br /> ❑ ❑ :11 F1 :1El1 <br /> 111211:1 El <br /> a <br /> If hydrostatic testing was performed,deseribe.what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONYfUCTING THIS TES MeTP rig we rr <br /> To the bat of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ( Date:_ 7" '-'° <br />