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SWRCB, January 2002 <br />Page 1 of 1 <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 appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACTLITY INFORNiATTnN <br />Facility Name: CHEVRON 307709 Date of Testing: 4/27/2012 <br />Facility Address: 10858 TRINITY PKWY , STOCKTON, CA 95219 <br />Facility Contact: MANAGER (N-7462-1-10) Phone: 952-2213 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): garret <br />2. TESTING CONTRACTOR INFORMATTON <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br />License Type: a License Number: 743160 <br />Manufacturer Trainim, <br />Manufacturer Component(s) Date Training Expires <br />TANKNOLOGY all 5/16/2014 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />ested <br />Repair <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box 1 unleaded fill <br />X <br />Spill Box T-2 premium fill <br />Spill Box T-3 diesel fill <br />X <br />I f hydrostatic testing was performed, describe what was done with the water after completion of tests: taken water trailer <br />CERTiF'ICATION OF TECHMCIAN 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: 4/27/2012 <br />WO: 2302101 <br />