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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(f 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 Date of Testing:2016-03-04 <br /> Facility Address: 1960 WEST 11TH ST,TRACY CA 95376 <br /> Facility Contact: I Phone ❑Initial ❑Repair Test <br /> Date Local Agency Was Notified of Testing: 2/26/2016 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(if present 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 ✓❑ICC UST Service Technician <br /> License Type: A C21 Cao B C61/D40 HAZ C34 I 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 Tank Annular ❑ 11 1:1 El UDC 7/8 21 ❑ El [I91 Tank Annular © 11 El UDC 9/10 � ❑ El El <br /> Diesel Tank Annular m ❑ El El UDC 11/12 � ❑ ❑ ❑ <br /> 87 Prod Sec Line © El 11 El 87 Fill Sump El El 11 El <br /> 91 Prod Sec Line 0 El El El 91 Fill Sump El ❑ ❑ <br /> Diesel Prod Sec Line © ❑ 11 ❑ Diesel Fill Sump El El ❑ <br /> 87 STP Sump <br /> © ❑ ❑ ❑ 87 Fill Bucket ❑ ❑ ❑ <br /> 91 STP Sump © ❑ ❑ ❑ 91 Fill Bucket 0 ❑ ❑ ❑ <br /> Diesel STP Sump m ❑ ❑ ❑ Diesel Fill Bucket ❑ ❑ ❑ <br /> UDC 1/2 © ❑ ❑ 87 Vapor Bucket ❑ ❑ ❑ <br /> UDC 3/4 © ❑ ❑ ❑ 91 Vapor Bucket <br /> ❑ ❑ ❑ <br /> UDC 5/6 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 Signature: Date: 2016-03-04 <br /> 0 <br />