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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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 208117 Date of Testing:2016-03-02 <br /> Facility Address: 755 S.TRACY BLVD,TRACY CA 95376 <br /> Facility Contact: I Phone ❑Initial E] air Test <br /> Date Local Agency Was Notified of Testing: 2/23/2016 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(if present during testing): p Triennial <br /> 2.. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nicholas Harvey-ICC#5115738 <br /> Credentials: Q CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester 0 ICC UST Service Technician <br /> License Type: A C21 C10 B C61/D40 HAZ c34 License Number: 300345 <br /> Manufacturer Trainine <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 Tank Annular ® ❑ ❑ ❑ 87 Fill Sump ❑ ❑ ❑ <br /> 91 Tank Annular © ❑ ❑ ❑ 91 Fill Sump 0 ❑ ❑ ❑ <br /> 87 Secondary Pipe ❑ ❑ ❑ ❑ 87 Fill Bucket ❑ ❑ ❑ ✓❑ <br /> 91 Secondary Pipe <br /> © ❑ ❑ ❑ 91 Fill Bucket IZI ❑ ❑ ✓❑ <br /> 87 Piping Sump m ❑ ❑ ❑ 87 Vapor Bucket IZI ❑ ❑ ❑ <br /> 91 Piping Sump © ❑ ❑ ❑ 91 Vapor Bucket 0 ❑ ❑ ❑ <br /> UDC#1/2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#3/4 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#5/6 ❑ ❑ D ❑ ❑ ❑ ❑ ❑ <br /> UDC#7/8 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#9/10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#11/12 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,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 /> Technician's Signature: Date: 2016-03-02 <br />