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L"4L6 <br /> Secondary Containment Testing Report Form JUN 2 7 2016 <br /> This farm is Intended for use by contractors performing periodic testing of UST secondary containment s st U <br /> �y 'e7V <br /> P 0%* <br /> appropriate pages ofthis form to report results for all components tested The completed form, written!test d <br /> printouts from tests(ifapplicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON Date of Testing: 6/20/2016 <br /> Facility Address: 444 MOSSDALE AVE,LAT OP' County SAN JOAQUIN <br /> Facility Contact: Phone: <br /> I Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: B.Z.Service Station Maintenance <br /> Technician Conducting Test: DAVID ROUSE <br /> Credentials: CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: ]CC I License Number:433159 <br /> Manufacturer Trainin <br /> Manufacturer Component(s) Date Training Exp!Ts <br /> INCON TS-STS 9/2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> 1: 1 Made <br /> ANNULAR Tested Made Tested - <br /> L <br /> E <br /> I L 11 17 1 <br /> 11 1 E: I I L1 <br /> F- <br /> El --- <br /> I E L <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK AS TEST WATER <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In h current re accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:6/20/16 <br /> Secondary Containment Test Results I of 3 <br /> -- ------------ - ------ <br />