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TS7393-05 a a Page_I—of—2— <br /> Secondary 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 rifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHELL OIL PRODUCTS—STOCKTON TERMINAL I Date of Testing: 11/13/06 <br /> Facility Address: 3515 NAVY DRIVE, STOCKTON,CA <br /> Facility Contact: GERALD LANG Phone: 209-466-6941 <br /> Date Local Agency Was Notified of Testing: 48 HOURS PRIOR(MIN-) <br /> Name of Local Agency Inspector(ifpresent during testing): Raymon Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: MICHAEL L. STRAWN II <br /> Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> Manufacturer Trainint= <br /> Manufacturer Com nent s) Date Training E fires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Re airs <br /> Component Pass Fail Tested RMade epairs Component Pass Fail Tested Made <br /> TANK ANNULAR(RECLAIIvi) ® ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ Li <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ <br /> El <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> Li❑ ❑ ❑ ❑ <br /> El 0 <br /> El Li ED] <br /> LJ <br /> ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSHILE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fads stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 11/13/06 <br />