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Page 1 of 9 <br /> • 4-WRCO.January 2002 <br /> Secondary Containment Testing Report Form <br /> F� E[I',�/FFD <br /> This form is intended for use by contractors perJorrning periodic testing of UST secondary containment systems. Use the appropriate pages of this fbr-rn <br /> to report results fur all components tested The completed form,wriffen test procedures,and printouts fi'orn tests(if applicable),sQ�4e g-oyd,�N2 <br /> the facilityowner,%operator for-submittal to the local re,gulofury agency. <br /> ENVIRONMENT HEALTH <br /> 1. FACILITY INFORMATION - <br /> Facili Name:Chevron I Date of Testing:. 12-04-02 <br /> Facility Address f 4a E. Lathro Lathrop,CA 95.330 <br /> Facility Gontact Phone <br /> Date Local Agency Was Notified of Testirt : <br /> Name of Local Agen2l Inspector Cif present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CoMp2ny Name'LC Services <br /> Technician Conduchng Test.Skip Cox <br /> Credentials:CSLS Licensed Contractor <br /> License Tv :A JAZ License Number:779267 <br /> Manufacturer Training <br /> Manufacturer Com nent s Date Training Expires <br /> Incon TS-STS <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Annuiac Tank 91 ❑ UCD DOSP 7$ El \+ D F1 <br /> Annular Tank 89 ❑ ❑ i] UDC DfSP 9-10 Ll <br /> AnnularTank87 ❑ 1 ❑ UDGgISP11-12 �� ''1 Q ❑ <br /> Piping Run 91 Ll ❑ L Fill 91 4 L7 0 <br /> Piping Run 89 C1 Ll 0 VR 91 ❑ <br /> Piping Run 67 "+f ❑ L ❑ Fill 89 1r ru ❑ L <br /> STP Sump 91 '1i LT L L VR 89 ❑ ❑ `❑ <br /> STP Sump 89 VI ❑ Q ❑ Fill 87 11 L © L <br /> STP Sump 87 ❑ ❑ ❑ VR 87 Ll ® ❑ <br /> UDC DISP 1-2 of Q ❑ Q D ❑ ❑ ❑ <br /> uDC DISP 3-4 i L ❑ ❑ G ❑ G <br /> uDC DISP 5 s CI ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was perfonw&describe what was dome with the water after cora kNion of tests: <br /> Water Is returned track into test tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TEST <br /> 7'o the best ofrnyv knowledge-the facts stated in this document are accurate and in I dl compliance with legal requirements <br /> Technician's Signature: Date: <br />