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Page 1 of <br />Corrected Summary Page --Secondary Containment Testina Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Ilse the <br />appropriate pages of thisform to report results for all components tested. The completedform, written lest procedures, and <br />printouts from tests (f applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY I NTORAIATION <br />Facility Name: CHEVRON #216997 Date of Testing: 8114/2012 <br />Facility Address: 1442A COLONY DR / JACK TONE RD, RIPON, CA 95366 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: Sf712012 <br />Name of Local Agency Inspector (f present during, testing). <br />2. TESTING CONTRACTOR MORNLMON <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 I License Number: 300345 <br />I Manufacturer Training — — <br />Manufacturer Component(s) Date Training Expires <br />Furnished on request -^ <br />3. SUAINIARYI OF TEST RESULTS <br />Component Piss <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87 Annular <br />E1 <br />0 � <br />❑ <br />UDC 11112 <br />M❑I <br />El <br />1 ❑ <br />91 Annular <br />Z El❑El <br />87 Fill Sump <br />® <br />❑ <br />1 ❑ <br />87 Prod Secondary Line <br />❑ <br />❑ <br />91 Fill Sump <br />Ell <br />❑ <br />I❑ <br />91 Prod Sewndaq Line <br />® <br />11❑ <br />❑ <br />87 Fill Bucket <br />❑ <br />❑ <br />❑ <br />87 Vent Secondary Line <br />0 El <br />I El <br />El <br />91 Fill Bucket <br />❑ <br />❑ <br />❑_ <br />91 Vent Secondary Line <br />201 <br />Ej <br />❑ <br />87 Vapor Bucket <br />z <br />❑ <br />1 ❑ <br />❑ <br />Vapor Return Secondary Line <br />❑ <br />❑ <br />❑ <br />I ❑ <br />91 Vapor Bucket <br />® <br />❑ <br />❑ <br />❑ <br />87 STI' Sump ❑ <br />( ❑ ❑ I <br />❑ <br />91 STP Surn <br />® <br />❑ <br />❑ <br />Eli <br />❑ <br />I <br />❑ <br />UDC 1/2 <br />❑ <br />❑ <br />❑ <br />01 <br />❑ <br />❑ 1 <br />❑ <br />UDC 3/4 <br />Z Ell <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 5/6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 7/8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 9110 <br />0 H <br />❑ <br />L El. <br />0 <br />❑ <br />❑ 1 <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />One (1) 55-zallon drum was left on site <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 />E <br />Technician's Signature: L d Date: 8/14/2012 <br />