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SWRCB, January 2002 • Page ofq <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 (f c Pner/operator for submittal to the local regulatory agency. <br />Chevron #20-1383 TION1960 W. 11'b St. <br />Facility Name: Tracy, Ca 95376 Date of Testing: e <br />Facility Address: S13989 Nick Harvey <br />Facility Contact: #N11093 Phone: <br />Date Local Agency Was Notified of Testing : L -1 b — <br />Name of Local Agency Inspector (if present during testing): <br />♦ /•ITAT TATT/1T 7�/f T TTCIAT <br />A. JL NI jj1\<T liVl\1a�llva vas -- <br />Company Name: Wayne Perry, Inc <br />Technician Conducting Test: _,,0 j e C 1-1,41? j,, i ICC# 5-115- y 3 T <br />Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, B, c10, C21 / D40 Haz License Number 300345 <br />Manufacturer Training <br />Manufacturer Comr)--41"N Date Training Expires <br />Furnished Upon Request <br />-. K ♦ "X7 AT TLOCCT UL'QTTT We <br />J• <br />0 V 1VJUViLliX <br />a va' <br />a _"•N <br />i - <br />Not <br />Repairs <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Tested <br />Made <br />q 7 <br />❑ <br />❑ <br />El <br />u Dc 7- <br />❑ <br />❑ <br />❑ <br />t, .t <br />❑ <br />❑ <br />❑ <br />e r 9 -rte <br />W <br />❑ <br />❑ <br />❑ <br /><< X31 <br />® <br />❑ <br />❑ <br />❑ <br />®, <br />❑ <br />❑ <br />❑ <br />l W 7 <br />❑ <br />❑ <br />❑ <br />1,;U-' � T:7 <br />50 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />17 <br />® <br />❑ <br />❑ <br />❑ <br />� <br />K <br />El <br />11 <br />11 <br />YL(Lk <br />El <br />El <br />El <br />17 <br />El <br />El <br />El <br />® <br />❑ <br />0 <br />❑ <br />Uri z�Fi i3� 9-7 <br />R <br />❑ <br />❑ <br />❑ <br />S^4 <br />9 <br />❑ <br />❑ <br />❑ <br />" 13 <br />❑ <br />❑ <br />❑ <br />� <br />If hvdrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECW11ICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />R <br />Technician's Signature: /4 Date: j J <br />