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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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 208118 Date of Testing: 04/16/2008 <br /> Facility Address: 3355 E. HAMMER LANE STOCKTON, CA, 95212 <br /> Facility Contact: MANAGER Phone: (2 0 9) 477-3699 <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: KELVIN CRUZ <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: SPILL BKT I License Number: 5254041-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BKTS 01/08/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> ss <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 SUP FILL � 0 ❑ ❑ El El <br /> Spill Box 2 UNL FILL X ❑ ❑ ❑ E <br /> El <br /> El M El El F-1 E <br /> E El El E ❑ El <br /> E El F-1 ❑ E <br /> El El E <br /> E] E F-1 El <br /> E ❑ ❑ ❑ ❑ ❑ <br /> Ell El I El ❑ E <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PLACED IN DRUM. <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: G�� Date: 04/16/2008 <br />