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SWRCB, January 2002 <br />Secondary Containment Testing Report Form FEB 10 2014 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment sy t ro riate <br />pages of this form to report results for all components tested. The completed form, written test procedures, PRAL <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. HEALTH DEPARTMENT <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON # 96171 (N-621-1-3) jDate of Testing: 1/30/2014 <br />Facility Address: 6633 PACIFIC AVE , STOCKTON, CA 95207 <br />Facility Contact: MGR - SUE LYNN Phone: 209-477-4294 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): aris cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials: W CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License TYDe: a License Number: 743160 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />tanknology all 5/16/2014 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box Tl supreme fill <br />X <br />Spill Box regular I regular fill <br />X <br />Spill Box regular 2 regular fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water trailer <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:`' Date: 1/30/2014 <br />WO: 2314881 <br />