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SWRCB, January 2002 Page 1. <br />Seton 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: SHELL CC # 13 618 7 <br />Date of Testing: 0 7 / 2 6 / 2 0 0 7 <br />Facility Address: 2375 WEST GRANT LINE ROAD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 8 3 6- 8 9 0 8 <br />Date Local Agency Was Notified of Testing : / / <br />Name of Local Agency Inspector (if present during testing): <br />i ', �;' �' ,, �, <br />Company Name: TANKNOLOGY , INC . <br />Technician Conducting Test: <br />KELVIN CRUZ <br />Credentials: <br />� <br />CSLB Licensed Contractor <br />❑SWRCB <br />Licensed Tank Tester <br />License Type: SPILL BKTS <br />Manufacturer <br />License Number: 1424 <br />Manufacturer Training <br />Components) <br />Date Training Expires <br />PHIL TITE <br />SPILL BKTS <br />03/01/2008 <br />:. <br />/ / <br />/ / <br />��QO' <br />/ / <br />3. SUM Y OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />USED FUEL AND RETURNED TO TANK. <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: 0 7/ 2 6/ 2 0 0 7 <br />:. <br />000` <br />��QO' <br />:. �� <br />000 <br />_ <br />���0' <br />. :... �0000� <br />a000 <br />�����0000 <br />0000 <br />���■��0000 <br />0000 <br />��� <br />000a <br />■000c� <br />0000� <br />0000� <br />■ <br />0000 <br />■ <br />■ <br />■ <br />■ <br />0000 <br />■ <br />■ <br />■� <br />0000 <br />0000 <br />0000 <br />0000 <br />__ <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />USED FUEL AND RETURNED TO TANK. <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: 0 7/ 2 6/ 2 0 0 7 <br />