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4RECEIVED <br /> Page 1 of 2 <br /> Secondary Containment Testing Report Form DEC 18 2013 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containme <br /> appropriate pages of this form to report results for all components tested. The completed form, writte <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the loca regu atory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON#208117 1 Date of Testing: 12/03/2013 <br /> Facility Address: 755 S.TRACY BLVD,TRACY,CA 95376 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 11/25/2013 <br /> Name of Local Agency Inspector(ifpresent 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 License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 3 /4 ❑ <br /> UDC7/ 8 El 1 ❑ El <br /> UDC 9/10 1 ❑ El <br /> UDC 11/12 ❑ ❑ ❑ ❑ ®I ❑ ❑ <br /> ❑ 11 ❑ <br /> Ell ❑ 0 ❑ ❑ ❑ <br /> El 1 ❑ ❑ ❑ ❑ <br /> El 01 ❑ I EllI ❑ I ❑ <br /> ❑I ❑ ❑ I ❑ ❑ 11 ❑ <br /> 1:1 El El <br /> 01 El -7 Ell El El <br /> ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,th ac`s sta/ed�int 's document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 12/03/2013 <br />