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RECEWED <br />Page <br />of <br />6 Month Post Repair -Secondary Containment Testing Reportl&%P13 <br />This form is intended for use by contractors performing periodic testing of UST secondary containmen <br />appropriate pages of this form to report results for all components tested. The completed form, written e W <br />NT <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 #208118 Date of Testing: 6/24/2013 <br />Facility Address: 3355 HAMMER LANE, STOCKTON, CA 95212 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : 6/11/2013 <br />Name of Local Agency Inspector (fpresent during testing): <br />Company Name: Wayne Perry, Incorporated <br />Technician Conducting Test: Nick Harvey ICC #5115738 <br />Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, HAZ, C21, C10, B, C61, D40 License Number: 300345 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Furnished on request <br />3. SUMMARY OF TEST RESULTS <br />IF Component <br />— 'Em <br />7.1 M., <br />Component <br />MM <br />all <br />/1� <br />■��% <br />��00 <br />87 <br />��■ <br />C�0 <br />91 Fill Bucket <br />/1� <br />■00 <br />��©�, <br />C�00 <br />��■ <br />00! <br />NOW <br />�■ <br />DOD <br />CM00■ <br />CM00 <br />�■ <br />SOD <br />Cm■ <br />UM! <br />DDD© <br />C�00 <br />©OD <br />�■ <br />X00; <br />C�00 <br />��00 <br />!� - __ --------Com■_-__OCA-------- <br />- --_--- -- <br />_��__■0_0, <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />One (1) 55 -gallon drum was left on site <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:_6/24/2013 <br />