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7 7 <br /> Pagel of 2 <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#208117 1 Date of Testing: 6/05/2013 <br /> Facility Address: 755 S.TRACY BLVD,TRACY,CA 95376 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : 5/28/2013 <br /> Name of Local Agency Inspector(tfpresent during testing): Thuy Tran <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 /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 3 /4 F ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7 / 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ❑ ❑ ❑ 9 ❑ ❑ ❑ ❑ <br /> UDC 11/12 E Ell ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ ❑ ❑ I ❑ <br /> ❑ I ❑ ❑ I ❑ El ❑ 1 ❑ <br /> ❑ I ❑ ❑ ❑ ❑ I ❑ <br /> El ❑ I ❑ ❑ ❑ ❑ I ❑ I ❑ <br /> ❑ F-1 ❑ F-1 El El❑ ❑ <br /> ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ 1 1 ❑ 101 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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 Signature: Date: 6/05/2013 <br />