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E ,R EIVED <br /> C, 11 <br /> SWRCB,January 2002 MAY 01 2017 <br /> Secondary Containment Testing Report Form <br /> Nv@QN fVTAL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmen systems, se <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedu- 9 T <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: DP&DK I Shell Date of Testing: 04121/17 <br /> Facility Address: 1206 March Ln.,Stockton,CA 95210 <br /> Facility Contact: NIA I Phone: NIA <br /> Date Local Agency Was Notified of Testing : 04118/17 @2:19pm via email <br /> Name of Local Agency Inspector(if present during testing): Not Present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CGRS, Inc. <br /> Technician Conducting Test: Richard Thomas <br /> Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: C61/D40/D64 803616(CSLB Lic.) License Number: 803616(CSLB Lic.)06-1672(SWRCB Lic.) <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC CA UST SERVICE TECHNICIAN: #5254736 11/17/2018 <br /> ICC UST TANK TIGHTNESS TESTING: #5254736 0310812018 <br /> SCWRCB TANK TESTER LICENSE: #06-1672 06130/2018 <br /> FRANKLIN FUELING INCON SUMP TESTER: #1001773708 0210612019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not —epairNot Re airs <br /> Component Pass Fail T sted RMades Component Pass Fail Tested Made <br /> T-1 87 Tank Annular ® ❑ ❑ ❑ UDC#6 ® ❑ ❑ ❑ <br /> T-1 87 Product Line ® ❑ ❑ ❑ UDC#7-8 ® ❑ ❑ ❑ <br /> T-1 87 STP Sump ® ❑ ❑ ❑ UDC#9-10 ® ❑ ❑ ❑ <br /> T-2 91 Tank Annular ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-2 91 Product Line ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-2 91 STP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-3 Diesel Tank Annular ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-3 Diesel Product Line ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-3 Diesel STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#1-2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#3-4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#5 ® I ❑ ❑ ❑ ❑ ❑ D ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING 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: �`" . U�_5 Date: 04/21117 <br />