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i <br /> Page 1 of 9 <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 applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON#201761 Date of Testing: 12/04/2012 <br /> Facility Address: 1103 SOUTH MAIN STREET,MANTECA,CA 95337 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 11/28/2012 <br /> Name of Local Agency Inspector(if present 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,CIO,B,C61,D40 I License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> Furnished 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 /> 87-1 Annular E ❑ ❑ ❑ 87-1 Fill Sump ® ❑ ❑ ❑ <br /> 87-2 Annular E ❑ ❑ ❑ 87-2 Fill Sum ❑ ® ❑ ❑ <br /> 91 Annular z ❑ ❑ ❑ 91 Fill Sump ❑ ® ❑ ❑ <br /> 87 Prod Secondary Line ❑ ❑ ❑ 87-1 Fill Bucket ® 1 01 ❑ <br /> 91 Prod Secondary Line ❑ ❑ ❑ 87-2 Fill Bucket ® ❑ ❑ ❑ <br /> 87-1 STP Sump ❑ ❑ I ❑ 191 Fill Bucket ® ❑ ❑ I ❑ <br /> 87-2 STP Sump ❑ ❑ I ❑ 87-1 Vapor Bucket ® ❑ I ❑ ❑ <br /> 91 STP Sump ❑ ❑ ❑ 1 87-2 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 1/2 E ❑ ❑ 1 ❑ 91 Vapor Bucket ® ❑ I ❑ ❑ <br /> UDC 3/4 F ❑ ❑ II ❑ ❑ ❑ <br /> UDC 5/6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ❑ ❑ ❑ ❑ ❑I ❑ I ❑ <br /> UDC 11/12 ❑ ❑ 1 ❑ ❑ ❑ I ❑ 1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> One(1) 55-gallon drum was left on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the f cts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:_12/04/2012 <br />