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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of I <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. FACILITY INFORMATION <br />Facility Name: CHEVRON 307709 jDate 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 INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials: C CSLB Licensed Contractor [7 SWRCB Licensed Tank Tester <br />License Type: a ILicense Number: 743160 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />TANKNOLOGY all 5/16/2014 <br />3. SUMMARY OF TEST RESULTS <br />Not RepairsNot Repairs <br />Component Pass Fail este Made Component Pass Fail Tested Made <br />Spill Box 1 UNLEADED F X <br />Spill Box T-2 PREMIUM F X <br />Spill Box T-3 Diesel F X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: taken water trailer <br />CERTIFICATION OF TECUMCIAN 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 />