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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of 1 <br />Phis 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 rest procedures, and printouts from tests <br />(if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 210997 (N4693) jDate of Testing: 2/2/2012 <br />Facility Address: 1442A COLONY DR. , RIPON, CA 95366 <br />Facility Contact: PATTY Phone: 599-0149 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Joey Mesa <br />Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tcstcr <br />License Type: TCC SF?RVICE TECH. <br />License. N'Umbcr: 5-50454-U7 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />OPW <br />SPILL BUCKET 9115/2013 <br />3. SUMMARY OF TEST RESULTS <br />Component PassFail Not Repairs Component Pass ,pail Not Repairs <br />TestedMade Tested Made <br />Spill Box TI: SUPREME UNLEADED PREMIUM F X <br />Spill Box T2:REGULAR UNLEADED REGULAR F X <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, the facts .stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: �1y Date: 212/2012 <br />