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Page I of t "Seconda� Containment TestingRe of t Form ECE9 Y/ECDI This form is intended for use by contractors performing periodic testing of UST secondary containment sysl(srf, Usg,t e appropriate pages of this form to report results for all components tested. The completed form, written test proce Us s _ r{ 1 printouts from tests (if applicably rator for submittal tot N*Wq gent Chevron # 201383 PERMIT/s Eavas Facility Name: 196 W. 1 1 Sheet Date of Testing: �%- /r. C Facility Address: Tracy, CA 95387 Facility Contact: N05203 -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: = Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A B ASB C-10 HAZ D40 Manufacturer License Number: 300345 Manufacturer Trainine Component(s) Date Training Expires SUPPLIED UPON REQUEST 3. SITMMARY OF TEST RESULTS 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: N Date: 000 r _ EN M� -- 0000 ow 0000 MMM� ME MFMWM�MMEMMM� -IMM " 00M� 000 0000... MM� 0000 000v 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: N Date: