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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 98264 Date of Testing:05/18/2016 <br /> Facility Address: 3775 TRACY BLVD,TRACY CA 95376 <br /> Facility Contact: I Phone ❑ Initial p Repair Test <br /> Date Local Agency Was Notified of Testing: 05/04/2016 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(f present during testing): Vicky McCartney ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nicholas Harvey ICC#5115738 <br /> Credentials: p CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester p ICC UST Service Technician <br /> License Type: A C21 C10 B C61/D40 HAz C3a 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 STP Sump 21 ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ [1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ [I ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El ❑ ElEl <br /> 1] 11 El El El I] EJ <br /> El El El 11 1:1 El <br /> El El El ❑ ❑ El <br /> ❑ ❑ El El 11 11 11 <br /> If hydrostatic testing wasrperformed,describe what was done with the water after completion of tests: <br /> ff <br /> 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 /> Technic* s S*'igna e: Date: 05/18/2016 <br />