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3 E C77 , <br /> 5 <br /> Page 1 of 8 �-4,,,� ep���, <br /> Secondary Containment Testing Repo k _i d <br /> TH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containg11"I rt s Use e <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(af 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: 07/21/2017 <br /> Facility Address: 16500 S. Harlan Road, Lathrop, CA 95330 <br /> Facility Contact: Chris I Phone: (209) 983-0381 <br /> Date Local Agency Was Notified of Testing: 07/17/2017 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nik Zagorov <br /> Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: A License Number:958763 <br /> Manufacturer Traininz <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Instruments, Inc. Level Change Indicator 12/01/2017 <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 Rd-n-0- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 2 Secondary Pipe Sump ElEl <br /> 4 UDC ❑ ❑ I ❑ El ❑ ❑ <br /> El L1 <br /> El I El <br /> ❑ ❑ ❑ 10 10❑ ❑ ❑El F-1 El El <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ <br /> ❑ ❑ ❑ I ❑ Ell ❑ I ❑ 1 ❑ <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: r oV Date:07/21/2017 <br />