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SWRCB, January 20020 <br />Page 1. <br />Secondary Containment Testing ReAt 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 completedform, written testprocedures, and <br />printouts from tests (3fopplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 91452 (N-618) <br />Date of Testing: 10/12/2007 <br />Facility Address: 334 E. MAIN ST ® HWY 99, RIPON, CA, 95366 <br />Facility Contact: DEALER - DONNA <br />Phone: (209) 599-2313 <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 />Pass <br />Fail <br />Technician Conducting Test: JARROD <br />COOKE <br />Component <br />Credentials: <br />Fail <br />CSLB Licensed Contractor <br />❑ <br />SWRCB Licensed Tank Tester <br />El <br />License Type: a <br />License Number: 743160 <br />❑ <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/17/2009 <br />Tank Annular 2 PLU <br />Ifl <br />11 <br />1:1 <br />❑ <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repair <br />Made <br />Tank Annular 3 UNL <br />El <br />❑ <br />❑ <br />❑ <br />UDC 7/8 <br />❑ <br />❑ <br />❑ <br />Tank Annular 2 PLU <br />Ifl <br />11 <br />1:1 <br />❑ <br />❑ <br />❑ <br />❑ <br />E <br />Tank Annular 1 SUP <br />ff] <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />Secondary Pipe 3 UNL REG <br />Secondary <br />x <br />❑ <br />❑ <br />- <br />n <br />Secondary Pipe 2 PLU PLUS <br />Secondary Pipe 1 SUP SUP <br />x <br />❑ <br />❑ <br />M <br />El <br />El <br />❑ <br />❑ <br />Piping Sump 3 UNL <br />El <br />❑ <br />El <br />El <br />El <br />El <br />❑ <br />El <br />Piping Sump 2 PLU <br />E1101 <br />D <br />E <br />11 <br />❑ <br />El <br />- <br />El <br />Piping Sump 1 SUP <br />x <br />El <br />❑ <br />El <br />El <br />❑ <br />Ej <br />El <br />UDC 1/2 <br />x <br />❑ <br />❑ <br />❑ <br />1:1 <br />❑ <br />D <br />UDC 3/4 <br />M <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC S/6 <br />Efl <br />El <br />El <br />E-1 <br />El <br />El <br />ED <br />El <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water <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: Date: 10/12/2007 <br />