COMPLIANCE INFO_2001-2007 - Laserfiche WebLink

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Page I of 7 Secondary ContainmentTesting Report Fo WCENED This form is intended for use by contractors performing periodic testing of UST secondary containment s)#D#nl W01he appropriate pages of this form to report results for all components tested. The completed form, written test roced r printouts from tests(if applicable), should be provided to the facility owner/operator for submittal t ITd 3agency. 1. FACILITY INFORMATION Facility Name: Chevron-201761 Date of Testing: Facility Address: 1103 S MAIN ST Facility Contact: Manteca, CA 95337-5743 Phone: Date Local Agency Was Notified N04884-SB989 Testing Name of Local Agency Inspector 2. TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry Inc. Technician Conducting Test: Credentials: ®CSLB Licensed Contractor WRCB Licensed Tank Tester License Type: A B ASB C-10 HAZ D40 License Number:300345 Manufacturer Training Manufacturer Component(s) Date Training Expires SUPPLIED UPON REQUEST 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Z& " �.,�. ❑ ❑ ❑ / si ,,, 1 Xr ❑ ❑ ❑ mat ` ❑ ❑ ❑ :` X ❑ ❑ ❑ j}G- / 2 ❑ ❑ ❑ x 'J7 is ❑ ❑ ❑ t f lS C 2 ❑ ❑ ❑ � "7 ;4 vt- [9 O ❑ ❑ 416 C 1%* ❑ ❑ ❑ x - ❑ O ❑ La C -7 - ❑ D ❑ y �r�e ❑ El D ki D c '!e' El El El x 5: .6/i/ Sir ❑ ❑ ❑ fiyG //- /z ❑ ❑ ❑ ce �J/ Y mat a I� ❑ ❑ ❑ ❑ ❑ ❑ ❑ j4L ❑ ❑ ❑ ❑ ❑ ❑ sf ❑ ❑ ❑ ❑ ❑ ❑ g/ ❑ ❑ D 11 11El 111111 ❑fo—]:ff❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Z41M,L�� Date: ,- 3 0 ® o'