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SWRCB, January 200205 <br />Page _ of <br />Secondary Containment Testing Re <br />This form is intended for use by contractors performing periodic testing of UST on tems. Use the <br />appropriate pages of thisformto report results for all components tested. The orm, written test procedures, and <br />printouts from tests (if applicable), should be provided_ - the owner/operator submit R$ry agency. <br />'k. V I htl regulatory t) 6 <br />1. FACILITY INFORMATION <br />Facility Name: Lower Sacramento Chevron Date %W4 12/23/08 <br />Facility Address: 8660 Lower Sacramento Road, Stockton Ca 95210 I.T111 'V'41p&ARXIW41 <br />Facility Contact: Kama] Kapoor Phone: 209-W-2844 <br />Date Local Agency Was Notified of Testing: <br />1 Name of Local Agency Inspector (ii(present during testing): <br />Company Name: <br />Technician Condu <br />Credentials: <br />License TvDe: A <br />2. TESTING CONTRACTOR INFORMATION <br />JP Petroleum Service <br />,ting Test: Gabe Garcia <br />x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />.1 Manufacturer <br />Component <br />MOHR- <br />F UFUTM" Sow" <br />It <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Water was filtered and re ed to holding tank. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thefacts stated in th "' dogwent are accurate andin full compliance with legal requirements <br />Technician's Signature: Date: <br />