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SWRCJ#,Jatntary2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors petformingperlodic testing of t7ST secondary coniainmentsystems Use the <br /> appr,opiIate pages of this form to report results for all components tester- The completed form,-written test proaedttres, and <br /> printouts fi opn tests(i Chevron#i20-1761 owneiloperator for submittal to the local regulalm y agency. <br /> 1103 S.Main St FATION <br /> Facility Name: Manteca,Ca 95337 Date of Testing: <br /> Facility Address: Nick rvey. <br /> Facility Contact: 9N12393 SB 939 Phone: <br /> Date Local Agency Was Notified.of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTJNG CGNTRAC'.COR INFORMATION <br /> ConipanyName: Wayne Perry,Inc <br /> Technician Conducting Test: ICC## S//3- 7 a T- <br /> Credentials: 11 CSLB Licensed Contractor C SWRCB Licensed Tank Tester <br /> License Type: A,B,c10,C211.1 D40 Haz License Number: 300345 <br /> Manufacturer Traininu <br /> Manufacturer Com onen s Date Training Expires <br /> Fumished Upon Request <br /> 3. SUMT4ARY DETEST RESULTS <br /> Component Pass Fail "Wet Repairs Component ]Pass Fail Not Repairs <br /> p Tested Marie Tested Made <br /> ❑ ❑ ❑ 29 ❑ 0 ❑ <br /> 11 El <br /> _.... ..._.... .._.... q y.._.. _..❑..._..�._. ..❑.. ❑ .. <br /> ?7-1 P1 ❑ ❑ ❑ 0 ❑ ❑ IR <br /> .. Q7•z ❑ ❑ ❑ r, S'7-z M ❑ ❑ ❑ <br /> Nhydrostatic testing was performed,describe what was done with the grater after completion oftests: <br /> CERT)C,I+TCATIQN OF TECHNICIAN RE'SI'DNSJBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated lit this docuntent ere accurate and in fall compliance Wth legal requirements <br /> Technician's Signature: ✓o Date: f 2 - /1-17- <br />