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l <br /> SWRCE,J 2002 Page ofSecondary Containment <br /> Testing <br /> This form is intendedfor 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 thefacility ownerloperator for submittal to the local regulatory agency. <br /> . FACILITY INFORMATION <br /> FacilityN e: Wilson Way Chevron Date ofTesting: Oct.07,2014 <br /> Facility Address:437 Wilson Way,Stockton,C .95205 <br /> Facility Contact: Aklman Mehroki Phone: 209-942-2344 <br /> Date Local Agency Was Notified of Testing: Sept.25, 2014 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR C INFORMATIONOCT 3 0 2014 <br /> Company Ne:Relic le Petroleum Services Inc. <br /> Technician Coodu ° g Test Ernesto Ber a e <br /> Credentials: CSLB Licensed Contractor 0 S RC L <br /> ice e Tank T <br /> ester <br /> License A Llc eN ber; 383706 <br /> rer Tranin <br /> Manufacturer Component(s) <br /> Date Train' P <br /> x ires <br /> LT <br /> ICC Sevice Tech A .10,2015 <br /> INCON <br /> TS-STS Au .06 2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component pass ail Not Repairs <br /> Tested Made Vested Made <br /> Annular Space 87 0 ® ❑ ❑ ❑ Cl ❑ ❑ <br /> Annular Space 91 1 z ❑ ❑ ❑ ❑ 11 ❑ ❑ <br /> 'Secondary 57 ❑ ❑ ❑ ® ^u ® ❑ <br /> Secondary 91 ❑ ❑ ❑ El ❑ I—C ❑ <br /> STP Sump 87 ❑ ❑ ® ❑ ❑ d 0 <br /> STP Sump 91 9 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1 /2 2 0 ❑ ❑ G ❑ G <br /> UDC 3/4 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 0 ❑ ❑ ❑ ❑ ❑ ❑ 11 <br /> UDC 7/8 R I ❑ ❑ ❑ ❑ ® ❑ <br /> Fill Sump 87 ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump 91 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION F CIAN RESPONSIBLEFOR CONDUCTING THIS TESTING <br /> l'oahe best of nV knowledge, Is in this docunwnt are accurate and infull compliance with legal requirements <br /> Technician's Signature: Date: October 07,2014 <br />