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SWRCB, January 2002 Page 1. <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SHELL # 136186 <br />Date of Testing: 03/19/2007 <br />Facility Address: 3725 TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 835-7608 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANENOLOGY, INC. <br />mm�Kamm <br />Technician Conducting Test: <br />CHRISTIAN ELIAS <br />Credentials: <br />CSLB Licensed Contractor <br />Spill Box I REG FILLSpill <br />SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Box 3 PRE FILL <br />000' <br />3. SUMMARY OF TEST RESULTS <br />Component <br />mm�Kamm <br />Component <br />Spill Box I REG FILLSpill <br />Box 3 PRE FILL <br />000' <br />1��00' <br />000' <br />��00 <br />DDOQ' <br />„��00 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 />r <br />Technician's Signature: V Date: 03/19/2007 <br />