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e <br /> Page 1 of 7 <br /> Secondary Containment Testing Report Form <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. FACILITY INFORMATION <br /> Facility Name: CHEVRON#99840 JFDate of Testing: 12/21/2012 <br /> Facility Address: 4344 E WATERLOO RD,STOCKTON,CA 95215 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 12/12/2012 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Incorporated <br /> Technician Conducting Test: NICK HARVEY ICC#5115738 <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,HAZ,C21,C10,B,C61,D40 I License Number: 300345 <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> Fumished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Annular ❑ 87 Vapor Bucket <br /> 91 Annular ❑ 91 Vapor Bucket ❑ <br /> 87 Prod Secondary Line ❑ ❑ ❑ <br /> 91 Prod Secondary Line ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 STP Sum ❑ ❑ ❑ ❑ <br /> 91 STP Sum ❑ ❑ ❑ <br /> UDC 1 /2 ❑ ❑ ❑ <br /> UDC3 /4 E ❑ ❑ I ❑ <br /> UDC 5 /6 ❑ ❑ ❑ ❑ ❑ El <br /> UDC 7/ 8 ❑ ❑ ❑ ❑ I ❑I ❑ ❑ <br /> UDC 9/10 ❑ ❑ ❑ ❑ 1 ❑II ❑ <br /> UDC 11/12 El =-0- <br /> 87 <br /> 87 Fill Bucket R ❑ ❑ 1 ❑ <br /> 91 Fill Bucket IE] ❑ ❑ 1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> No drums were left on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,ffiefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: z< Date:_12/21/2012 <br />