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SWRCB, January 2002 Page 1. <br />0 0 <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: LOWER SACRAMENTO CHEVRON <br />Date of Testing: 02/25/2009 <br />Facility Address: 8660 LOWER SACRAMENTO STOCKTON, CA, 95210 <br />Facility Contact: LISA <br />Phone: (2 0 9) 477-2844 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): no present <br />CONTRACTOR2. TESTING <br />Company Name: TANKNOLOGY, INC. <br />Pass <br />Technician Conducting Test: <br />JARROD COOKE <br />Repairs <br />Made Component <br />Credentials: <br />Fail <br />CSLB Licensed Contractor <br />Repair ss <br />Made <br />SWRCB Licensed Tank Tester <br />License Type: a <br />Manufacturer <br />License Number: 743160 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/17/2009 <br />❑ <br />Tank Annular 2 PLU <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repair ss <br />Made <br />Tank Annular 3 UNL <br />❑ <br />❑ <br />❑ UDC 7/8 <br />Efl <br />❑ <br />❑ <br />❑ <br />Tank Annular 2 PLU <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I El <br />Tank Annular 1 SUP <br />E <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 3 UNL REG <br />IF--] <br />❑ <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 2 PLU PLUSF-❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />ELI <br />Secondary Pipe 1 SUP SUP <br />E <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 3 UNL <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 2 PLU <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 1 SUP <br />E <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 1/2 <br />P-71 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />EJ - <br />UDC 3/4 <br />Q <br />F-1 <br />1:1 <br />1:1❑ <br />❑ <br />F-1ElUDC <br />5/6 <br />1:1 <br />1:1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water dog <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: k --I— Date: 02/25/2009 <br />