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v0 <br />Pagel of 3 <br />Secondary Containment Testing Report Form <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, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: CHEVRON #208118 1 Date of Testing: 1/07/2013 <br />Facility Address: 3355 HAMMER LANE, STOCKTON, CA 95212 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : 1/02/2013 <br />Name of Local Agency Inspector (f present during testing): Garrett Backus <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 I License Number: 300345 <br />Manufacturer Training <br />Manufacturer Component(s)) Date Training Expires <br />Furnished on r uest <br />3. SUMMARY OF TEST RESULTS <br />Component <br />LIJ <br />/�00 <br />��r-7C101 <br />Bucket91 Fill <br />//[� <br />■OOI <br />��0■ <br />N <br />I' <br />I <br />Com■ <br />L�OI <br />�■ <br />� <br />■0��1 <br />C�00, <br />�■ <br />�■ <br />00; <br />CDDO� <br />C1L-10U!�' <br />CC■lC7C� <br />��■7C7L� <br />UN: <br />X00 <br />CW00 <br />��00 <br />CC70w <br />----- OMMMl------- <br />---- - -- "N <br />"M mm <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />No drums were left on site <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, th facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date:_1/07/2013 <br />