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Ll <br />0 <br />Page 1 of 9 <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON #96171 1 Date of Testing: 3/03/2014 <br />Facility Address: 6633 PACIFIC AVENUE, STOCKTON, CA 95207 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: 2/25/2014 <br />Name of Local Agency Inspector (cfpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <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 request <br />3. SUMMARY OF TEST RESULTS <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, facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date:_3/03/2014 <br />-1 <br />X00 <br />• <br />// <br />X00■ <br />Eel WIT,553 <br />�/� <br />■00/�■00■ <br />rellm- Ellin <br />• <br />M <br />0 <br />91 Fill Bucket6 <br />►1 <br />� <br />■00 <br />7-1 Vapor bucket <br />W3 11M loil <br />A7-2 Vapor Aucket <br />all <br />/1 <br />00■t <br />I VaporBucket <br />� - <br />/1 <br />� <br />■00 <br />�■ <br />X00 <br />►/ <br />■00 <br />��■ <br />■00 <br />: <br />►1 <br />00 <br />I■ <br />M■ <br />00 <br />all -6TW1 Ito <br />WWI <br />0■MMMM <br />��0 <br />■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, facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date:_3/03/2014 <br />