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Secondary Containment Testing Repo Form <br /> This form is intended for use by contractors performingperiodic testing of USTsecondary contcanment systems. Use the <br /> appropriate pages of thisform to report results far all components tested. The completed form, written testprocedres,and <br /> printcutsftom tests ffapplicable), should beprovidedto thefacility owner/operatorflbr submrittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:BP West Coast Products,LLC Date of Testing: 3 0 <br /> Facility Address:25775 S PATTERSON PASS City: TRACY Zip: 95376 <br /> Facility Contact: C j,►�y` Phone: ( Z,aR c 33"S•' <br /> Date Local Agency Was Notified of Testing, <br /> Name of Local Agenc Inspector(f'present duri tesfiri o-- <br /> 2. <br /> -2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: <br /> Technician Conducting Test: OVI%Ac t L <br /> Credentials: CSLB Licensed Contractor . IoSWRCB Licensed Tank Tester <br /> License Type: ,A 458 AA ZB 0—(D License Number. Q <br /> Manufactvnr TrabdW <br /> Manufacturer Component(i) Date Training Expires <br /> 3. SIJZV MARY.OE TEST RESULTS <br /> Co —Not—lgiiamr— <br /> mponent Pass Fail Teslet Made Cosn�onent F`�e FaB Tesied Made <br /> —.• ( ❑ ❑ . .... ❑ ❑ ❑ o ❑ <br /> s ❑ ❑. 1] 0 0 ❑ 0 <br /> 0 0 , ❑ 0 ❑ ❑ 0 <br /> ❑ 1 ❑ ❑ 0 ❑ ❑ 0 <br /> ❑ ❑, ❑ ❑ 0 ❑ ❑ <br /> 0 ❑ ❑ 0 ❑ ❑ ❑ <br /> E ❑ ❑ 0 ❑ ❑ o 0 <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑` ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ : ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑• ❑1E ❑ 0 a 0 <br /> Ifhydrostatic testingwas performed,describe what was done withthe water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN.MPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the bast of my knowledge,the facts stated in docm.ent are accermte and in fill compliance witk legal requiremonis <br /> J <br /> Technician's Signature: - Date: �(i-T= <br />