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SWRCB,,Tanuary 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: CHEVRON #99840 Date of Testing: 10/15/2007 <br /> Facility Address: 4344 WATERLOO RD , STOCKTON, CA, 95210 <br /> Facility Contact: MANAGER Phone: (2 0 9) 93 1-218 6 <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: TANKNOLOGY, INC. <br /> Technician Conducting Test: GREGORY MCHALE <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A I License Number: 74 316 0 <br /> Manufacturer Trainina <br /> Manufacturer Component(s) Date Training Expires <br /> TANKNOLOGY ALL 10/03/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular 3 REG P-11, ❑ ❑ ❑ ❑ ❑ 1:1 ❑ <br /> Tank Annular 1 SUP x ❑ ❑ ❑ ❑ ❑ ❑ El <br /> Secondary Pipe 1 SUP r �]� F-1 ❑ El ElEl <br /> � X <br /> Secondary Pipe 3 REG ElEl El <br /> ❑ E ❑ <br /> Piping Sump 1 SUP �� --x ❑ ❑ ❑ El ❑ ❑ E <br /> Piping Sump 3 REG X ❑ ❑ ❑ ❑ ❑ ❑ <br /> El- <br /> UDC 1/2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ❑ ❑ ❑ El El El EJ <br /> UDC 7/8 FRI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 11/12 El I <br /> ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TAKEN <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: iyi,y�� � Date: 10/15/2007 <br />