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Feb. 6. 2014 9:52AM <br />. N. <br />AM FroPw n <br />SWRCB, January 2002 ge f <br />I <br />Secondary Containment Vesting Report Form FES U b 2014 <br />This form is intended for use by contractors performing periodic testing of UST secondary containmentV1 NTA <br />appropriatepages of this form to report results for all components tested. The completedform, written Stwoolaw 'L <br />printouts from tests Chevron #208117 yowner/operator for suhmittal to the locoMregmu <br />UAPT <br />755 South Tracy Boulevard 1VfAT]C®N <br />Facility Name: Tracy, CA Date of Testing: / z - i q- i.3 <br />Facility Address: Jason Smith <br />#NI3620 Saw Work <br />Facility Contact: . I Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Ajeency Inspector (f present during testinje): <br />Company Name: <br />Wayne Perry, Inc <br />Technician Conducting <br />Test: Allrk Am vz ICC# S// S 7 3 <br />Credentials: d CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />A, B, 010, C21 / D40 Haz License Nwnber: 300345 <br />Manufacturer Training,., <br />Component(s) Date Training Expires <br />Furnished Upon Request <br />im lcTlTAI - : VZOW1 WN 0 2, 1 OM I 1 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />C)ERTl FICA.TION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TMS TESTING <br />To the Best of rrry knowledge, the facis stated in this document are accurate and th frsll compliance with legal requirements <br />Technician's Signature: Date: / z <br />Received Time Feb. 6. 2014 9:59AM No.5138 <br />aaoo <br />a000 <br />o00 <br />0000 <br />i <br />OMNI <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />C)ERTl FICA.TION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TMS TESTING <br />To the Best of rrry knowledge, the facis stated in this document are accurate and th frsll compliance with legal requirements <br />Technician's Signature: Date: / z <br />Received Time Feb. 6. 2014 9:59AM No.5138 <br />