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t <br /> t <br /> 0 0 eco,./' <br /> Page 1 of 8 <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 Date of Testing: 07/30/2014 <br /> Facility Address: 16500 S. Harlan Road, Lathrop, CA 95330 <br /> Facility Contact: Nick/Chris I Phone: (209) 983-0381 <br /> Date Local Agency Was Notified of Testing: 07/15/2014 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> =Conduc�fing <br /> ECO-CHEK Compliance, Inc. <br /> Test: Nik Zagorov <br /> CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> A License Number: 958763 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Instruments, Inc. Level Change Indicator N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 2 Annular Space ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 2 Secondary Pipe Run ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 2 Secondary Pipe Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4 UDC ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑❑ ❑El ❑❑ °❑ El El <br /> ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ ❑ <br /> ❑❑ ❑ ❑❑ ❑ ❑❑❑ ❑ El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Placed in a 550 gallon tank on a trailer and hauled for reuse as test water <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: rc>V Date:07/30/2014 <br />