Laserfiche WebLink
P P <br /> RECEIVED <br /> MAR 3 0 2017 <br /> Secondary Containment TestingReport Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment NTALLELT <br /> appropriate pages of this form to report results for all components tested. The completed form, written test proc�i" ,,R11M FE N T <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> t. FACILITY INFORMATION <br /> Facility Name: Chevron 209167 Date of Testing:03/06/2017 <br /> Facility Address: 1234 E.Yosemite Ave, Manteca,CA 95336 <br /> Facility Contact: I Phone ❑Initial ❑Repair Test <br /> Date Local Agency Was Notified of Testing: 02/21/2017 ❑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 0 ICC UST Service Technician <br /> License Type: A C21 Cao B C61/D40 HAz C34 License Number: 300345 <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 Z ❑ ❑ ❑ 87 Fill Bucket <br /> ✓❑ ❑ ❑ ❑ <br /> 91 Annular ® ❑ ❑ ❑ 91 Fill Bucket IZI ❑ ❑ ❑ <br /> 87 Prod Sec Line 171 ❑ ❑ ❑ 87 Vapor Bucket 0 ❑ ❑ ❑ <br /> 91 Prod Sec Line ® ❑ ❑ ❑ 91 Vapor Bucket 2 ❑ ❑ ❑ <br /> 87 STP Sump z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP Sump © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ® ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> UDC 11/12 ® ai ❑ ❑ I ❑ ❑ ❑ ❑ <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 /> 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: 03/06/2017 <br />