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SWRCB, January 2002 0 Page 1 . <br />Secondfoy 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 tot e facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 210997 (N-4693) <br />I DateofTesting: 02/07/2011 <br />Facility Address: 1442A COLONY DR. , RIPON, CA, 95366 <br />Facility Contact: PATTY <br />Phone: (2 0 9) 599-0149 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): Muni <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC _ <br />Technician Conducting Test: <br />STEVEN WILLEMS <br />Credentials: <br />CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: icc <br />I License Number: 8016974 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />phil tite <br />spill bucket <br />06/07/2012 <br />/ f <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />put in drum and labeled and left onsite <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: IhJ +x Date: 02/07/2011 <br />0000 <br />��00 <br />� <br />Q000 <br />��00 <br />0000 <br />��00 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />put in drum and labeled and left onsite <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: IhJ +x Date: 02/07/2011 <br />