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Page 1 of 9 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report resultsfor all components tested. The completed form, written test procedures, and printouts from tests(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON#98264 1 Date of Testing: 3/07/2013 Facility Address: 3775 TRACY BLVD,TRACY,CA 95304 Facility Contact: Phone: Date Local Agency Was Notified of Testing: 2/28/2013 Name of Local Agency Inspector('(present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry,Incorporated Technician Conducting Test: Nick Harvey -ICC#5115738 Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A,HAZ,C21,CIO,B,C61,D40 I License Number: 300345 Manufacturer Trainini< Manufacturer Component(s) Date Training Expires Furnished on request 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made 87 Annular ❑ UDC 11/12 ❑ I 89 Annular ❑ 87 Fill Sum ❑91 Annular ❑ ❑ 89 Fill Sum ® ❑ ❑87 Sec Line ❑ ❑ ❑ 91 Fill Sum ® ❑ ❑89 Sec Line ❑ ❑ 87 Fill Bucket ❑ ❑91 Sec Line ❑ ❑ ❑ 89 Fill Bucket ❑ ❑87 STP Sum ❑ ❑ ❑ 91 Fill Bucket ❑89 STP Sum ❑ 87 Va or Bucket91 STP Sum ❑ ❑ 89 Va or BucketUDC 1/2 ❑ ❑ ❑ 91 Va or Bucket ® ❑ ❑UDC 3/4 ❑ ❑ ❑ ❑ ❑UDC 5/6 ❑ ❑ UDC 7/8 ❑ ❑ UDC 9/10 ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: One (1) 55-gallon drum was left on site CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,1�he facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:. Date:_3/07/2013