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• • AEGEIVEL) <br />Par <br />Secondary Containment a AR 2015 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment <br />appropriate pages of this form to report results for all components tested. The completed form, written t 07N1 <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: CHEVRON #96171 1 Date of Testing: 3/2/2015 <br />Facility Address: 6633 PACIFIC AVENUE, STOCKTON, CA 95207 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: 2/13/2015 <br />Name of Local Agency Inspector (fpresent during testing): <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, AZ, C21, C10, B, C61, D40 License Number: 300345 <br />. . <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Furnished on request <br />' NTI- <br />• �- - <br />W <br />w00�0. <br />MimiM <br />mm <br />0 <br />■0 <br />� <br />/� <br />X00 <br />�■ <br />�00 <br />►� <br />o©r■� <br />aro <br />0000 <br />0000 <br />0000� <br />o000 <br />o©or�� <br />r�000 <br />0000 <br />0000 <br />ar�oo <br />oaoo <br />o000 <br />0000 <br />or�oo <br />000� <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, t, jze facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:, Date: 3/2/2015 <br />