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MAR 2 IS <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. else'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): ❑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 Tank Annular 0 ❑ ❑ ❑ UDC 7/8 <br /> ❑ ❑ ❑ ❑ <br /> 91 Tank Annular © ❑ ❑ ❑ UDC 9/10 [Z] ❑ ❑ ❑ <br /> Diesel Tank Annular 0 ❑ ❑ ❑ UDC 11/12 El ❑ ❑ ❑ <br /> 87 Prod Sec Line © ❑ ❑ ❑ 87 Fill Sump <br /> ❑ ❑ ❑ ❑ <br /> 91 Prod Sec Line 0 ❑ ❑ ❑ 91 Fill Sump 0 ❑ ❑ ❑ <br /> Diesel Prod Sec Line © ❑ ❑ ❑ Diesel Fill Sump [Z] ❑ ❑ ❑ <br /> 87 STP Sump © ❑ ❑ ❑ 87 Fill Bucket O ❑ ❑ ❑ <br /> 91 STP Sump 0 ❑ ❑ ❑ 91 Fill Bucket 0 ❑ ❑ ❑ <br /> Diesel STP Sump 0 ❑ ❑ ❑ Diesel Fill Bucket R1 ❑ ❑ ❑ <br /> UDC 1/2 0 ❑ ❑ ❑ 87 Vapor Bucket D ❑ ❑ ❑ <br /> UDC 3/4 0 ❑ ❑ ❑ 91 Vapor Bucket 0 ❑ ❑ ❑ <br /> UDC 5/6 © ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <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 />