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imGErriER-RYAN INC. IR Job# 20-630774.1 <br /> SWRCI3,January 2002 Page 1 of 3 <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 complete 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 /> 1. FACILITY INFORMATION <br /> Facility Name: West Valley Chevron Date of Testing: 5/26/2015 <br /> Facility Address: 2615 W Grant Line Road Tracy <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> I[Name of Local Agency Inspector(if present during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Cettler-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.91568 Ph.#925-551-7555 <br /> Technician Conducting Test: Chris San Nicolas <br /> Credentials: CSLB Licensed Contractor <br /> License Type: C57 B C61/1)40 H AZ A C10 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon Test System Operation Hydrostatic Testing 2/11/2015 <br /> Phil-Tito Spill Containment <br /> 101)'A Spill Containment 10/5/2014 <br /> ICC Technician L ST Components 12/6/2014 <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fail Components Pass Fail <br /> Tested Made Tested Made <br /> UDC 7-8 x <br /> Vent Sump X <br /> AIN —21n <br /> ICE <br /> dam <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTFICATION 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: 5/26/2015 <br />