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E <br />SWRCB, January 2002 <br />Page 1 of 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 appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 FACTT,TTV INFORMATION <br />Facility Name: CHEVRON # 96171 (N-621-1-3) jDate of Testing: 2/1/2013 <br />Facility Address: 6633 PACIFIC AVE , STOCKTON, CA 95207 <br />Facility Contact: MGR - SUE LYNN Phone: 477-4294 <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: Joey Mesa <br />Credentials: CSLB Licensed Contractor r— SWRCB Licensed Tank Tester <br />License Tvoe: ICC Service Tech. ILicense Number: 5259458 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Phil The Spill Bucket 9/15/2013 <br />Z CTTMMARV OF TF.CT RF,CTTT.TC <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 1 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: Left on site in hazardous waste <br />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: i Date: 2/1/2013 <br />WO: 2308159 <br />