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RECEIVED <br /> DEC 2 12015 <br /> Secondary Containment Testing Report Form ENVIRONMENTAL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systeXFP <br /> . bUiPgRVICES <br /> appropriate pages of this form to report results for all components tested. The completed form,written test procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> t. 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(if present during testing): ®Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nicholas Harvey ICC#5115738 <br /> Credentials: ®CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester ®ICC UST Service Technician <br /> License Type: A C21 C10 B C61ID40 HAz C34 License Number:300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> FURNISHED UPON REQUEST <br /> 3. SUM Y OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Annular ® ❑ ❑ ❑ 87 Fill Bucket 0 ❑ ❑ ❑ <br /> 91 Annular ® ❑ ❑ ❑ 91 Fill Bucket ❑ [IEl87 Prod Sec Line El ll 87 Vapor Bucket ® ❑ C191 Prod Sec Line ® ❑ ❑ El 91 Vapor Bucket 17 ❑ 1187 STP Sump ® El 11 El ❑ ❑ 1391 STP Sump ® 171 El ❑ 11 ❑ ElEl <br /> 1/2 ® ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> UDC 3/4 ® ® ❑ ❑ ❑ <br /> UDC 5/6 ❑ ® El El ❑ ❑ <br /> UDC 7/8 ® ❑ ❑ 0 0 ❑ 11 <br /> UDC 9/10 ® ❑ ® ❑ E ❑ <br /> UDC 11/12 ❑ ® ❑ 0 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> No drums 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 Signa red Date: 2015-11-30 <br />