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Secondary Containment Testing Report Form JAH 11 20 i <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. U,�e�ft I <br /> appropriate pages of this form to report results for all components tested. The completed form, written test proceduzes', iUk ' H <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency R 97, <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 99840 Date of Testing:2015-11-30 <br /> Facility Address:4344 E WATERLOO RD,STOCKTON CA 95215 <br /> Facility Contact: I Phone ❑Initial ❑Repair Test <br /> Date Local Agency Was Notified of Testing: 2015-11-20 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(ifpresent during testing): p Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nicholas Harvey ICC#5115738 <br /> Credentials: p CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester p ICC UST Service Technician <br /> License Type: A c21 c10 B c61/D40 HAZ C34 License Number:300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> FURNISHED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Annular 0 ❑ ❑ ❑ 87 Fill Bucket ✓❑ ❑ ❑ ❑ <br /> 91 Annular ® ❑ ❑ ❑ 91 Fill Bucket [Z] ❑ ❑ ❑ <br /> 87 Prod Sec Line 0 ❑ ❑ ❑ 187 Vapor Bucket IZI ❑ ❑ ❑ <br /> 91 Prod Sec Line © ❑ ❑ ❑ 91 Vapor Bucket ED ❑ ❑ ❑ <br /> 87 STP Sump 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 11/12 ❑ 1 ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> r!urns were 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 ❑ System printout attached. <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 /> Technician's Signna�e� Date: 2015-11-30 <br /> Iv <br />