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E0 <br />Page 1 of 3 <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON #96171 1 Date of Testing: 9/10/2014 <br />Facility Address: 6633 PACIFIC AVENUE, STOCKTON, CA 95207 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : 9/2/2014 <br />Name of Local Agency Inspector (present during testing): Robert Kubena (Stockton Fire) / Stacy Rivera (San Joaquin County) <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, C10, B, C61, D40 License Number: 300345 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Furnished on request <br />3. SUMMARY OF TEST RESULTS <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 O TECHNICIAN RESPONSH3LE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the is stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:d!A'l, Date: 9/10/2014 <br />Component <br />87 Prod Sec Line <br />FAI <br />91 Prod Sec Line <br />FAI <br />VAI <br />0000 <br />0000 <br />0000: <br />0000 <br />our���� <br />0000 <br />0000; <br />0000 <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 O TECHNICIAN RESPONSH3LE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the is stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:d!A'l, Date: 9/10/2014 <br />