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0 0 Page 1 of 9 <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 /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON#201383 1 Date of Testing: 3/08/2013 <br /> Facility Address: 1960 WEST 11TH STREET,TRACY,CA 95376 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 2/28/2013 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Incorporated <br /> Technician Conducting Test: Nick Harvey -ICC#5115738 <br /> Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A,HAZ,C21,C10,B,C61,D40 I License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished on 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 ❑ ❑ ❑ UDC 11/12 ® ❑ ❑ ❑ <br /> 89 Annular E ❑ ❑ ❑ 87 Fill Sum ® ❑ ❑ ❑ <br /> 91 Annular Z ❑ ❑ ❑ 89 Fill Sump ® ❑ ❑ ❑ <br /> 87 Sec Line ❑ ❑ ❑ 91 Fill Sump ® 1:11 ❑ ❑ <br /> 89 Sec Line ❑ ❑ 1 87 Fill Bucket ® ❑ ❑ ❑ <br /> 91 Sec Line ❑ ❑ ❑ 89 Fill Bucket ® ❑ ❑ ❑ <br /> 87 STP Sump ❑ ❑ I ❑ 91 Fill Bucket ® 1:111 ❑ 1 ❑ <br /> 89 STP Sump ❑ ❑ I ❑ 87 Va or Bucket ® ❑ ❑ 1 ❑ <br /> 91 STP Sump ❑ ❑ I ❑ 89 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 1/2 ❑ ❑ I ❑ 91 Va or Bucket ® ❑ I ❑ ❑ <br /> UDC 3/4 ❑ ❑ I ❑ ❑ ❑ I ❑ ❑ <br /> UDC 5/6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 ❑ ❑ I ❑ ❑ ❑ I ❑ 1 ❑ <br /> UDC 9/10 ❑ 1 ❑ 1 ❑ 1 ❑ 01 ❑ 1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> One(1) 55-gallon drum was left on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,t facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:_3/08/2013 <br />