Laserfiche WebLink
I <br />0 <br />RECD JILL 20 2015 <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 />I . FACILITY INFORMATION <br />Facility Name: Chevron 210997 Date of Testinto: 2015-07-06 <br />Facility Address: 1442A COLONY DRIVE, RIPON CA <br />Facility Contact: I Phone ❑ Initial <br />❑ Repair Test <br />Date Local Agency Was Notified of Testing; 2015-06-02 ❑ 6 Month <br />❑Other <br />Nance of Local Agency Inspector (ifpresew during testing): 0 Triennial <br />License Number: 300345 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Wayne Perry Inc <br />Pass <br />Technician Conducting Test: Nicholas Harvey <br />ICC #5115738 <br />Credentials: © CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester m ICC UST Service Technician <br />License Type: AC21C10BC61/D40HAZC34C57 <br />License Number: 300345 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />FURNISHED UPON REQUEST <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 718 <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />FailNot <br />tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87 Annular <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 718 <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Annular <br />© <br />❑ <br />❑ <br />❑ <br />UDC 9110 <br />Rl <br />El <br />El <br />El <br />87 Prod See Line <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 11112 <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Prod Sec Line <br />Q <br />❑ <br />❑ <br />❑ <br />87 Fill Sump <br />❑ <br />❑ <br />❑ <br />❑ <br />87 Vent Sec Line <br />❑ <br />❑ <br />Q <br />❑ <br />91 Fill Sump <br />® <br />❑ <br />❑ <br />❑ <br />91 Vent Sec Line <br />1Z <br />❑ <br />❑ <br />❑ <br />87 Fill Bucket <br />© <br />❑ <br />❑ <br />❑ <br />Vapor Return Sec Line <br />© <br />❑ <br />❑ <br />❑ <br />91 Fill Bucket <br />❑ <br />❑ <br />❑ <br />❑ <br />87 STP Sump <br />© <br />❑ <br />❑ <br />❑ <br />87 Vapor Bucket <br />❑ <br />❑ <br />❑ <br />❑ <br />91 STP Sump <br />© <br />❑ <br />❑ <br />❑ <br />91 Vapor Bucket <br />✓❑ <br />❑ <br />❑ <br />El <br />UDC 1I2 <br />© <br />❑ <br />P <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 314 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 5/6 <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />if hvdrostatic testin<o xas performed, describe what was done with the water after completion of tests: <br />No testing water left on site <br />For any equipment capable of generating a print out of test results, you must attach a copy <br />of the test report to this certification <br />CERTIFICATION OF TECHNICIA: <br />To the best of my knowledge, the facts state in this <br />Technician's Signature: <br />0 System printout attached. <br />RESPONSIBLE FOR CONDUCTING THIS TESTING <br />scum"tare accurate and in full compliance with legal requirements <br />Date: 2015-07-06 <br />