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RECEIVED <br /> Secondary Containment Testing Report For <br /> JUL 0 2 2018 <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, writ4Ef j%qqjW,PIE&TH <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to theojTgf � ency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Chevron 208118 Date of Testing:06/07/2018 <br /> Facility Address: 3355 E.Hammer Ln, Stockton,CA 95212 <br /> Facility Contact: I Phone ❑Initial ❑Repair Test <br /> Date Local Agency Was Notified of Testing: 05/18/2018 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(if present during testing): none p Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nick Harvey ICC#5115738 <br /> Credentials: p CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester ✓❑ICC UST Service Technician <br /> License Type: A C21 C10 B C61/D40 HAz C34 License Number: 300345 <br /> EMEMEMOMEW <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 Annular ❑ ❑ ❑ ❑ 87 Fill Bucket 0 ❑ ❑ ❑ <br /> 91 Annular ® ❑ ❑ ❑ 91 Fill Bucket 0 ❑ ❑ ❑ <br /> 87 Prod Sec Line 2 ❑ ❑ ❑ 87 Vapor Bucket 0 ❑ ❑ ❑ <br /> 91 Prod Sec Line ® ❑ ❑ 1 ❑ 91 Vapor Bucket 0 ❑ ❑ 1 ❑ <br /> 87 STP Sump l] ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 11/12 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> rf <br /> 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: 06/07/2018 <br />