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4 <br /> RECEIVED <br /> X01 2016 <br /> Secondary Containment Testing Report For <br /> EIR®f� EN AL HEALTH <br /> Thisform is intended for use by contractors performing periodic testing q1'UST secondary containment sysMN <br /> VIES <br /> appropriate pages of this form to report results for all components tested. The completed form, written test proce ures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> t. FACILITY INFORMATION <br /> Facility Name: Chevron 201383 Date of Testing:07/08/2016 <br /> Facility Address: 1960 WEST 11TH ST,TRACY CA 95376 <br /> Facility Contact: I Phone ❑Initial ❑Repair Test <br /> Date Local Agency Was Notified of Testing: 06/21/2016 P1 6 Month ❑Other <br /> Name of Local Agency Inspector(f present during testing): ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nicholas Harvey ICC#5115738 <br /> Credentials: p CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester ✓❑ICC UST Service Technician <br /> License Type: A C21 C10 a C61/D40 HAz C34 License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> FURNISHED UPON 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 Prod Sec Line ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Prod Sec Line ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Prod Sec Line IZI 1 ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 11/12 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <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 /> For any equipment capable of generating a print out of test results,you must attach a copy <br /> of the test report to this certification ❑ System printout attached. <br /> CERTIFICATION OF TECHNICIAN 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 /> Technician's Signa Date: 07/08/2016 <br />