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SWRCB,January 2002 Page 1. <br /> Second Containment Testing Rep t 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(af applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON #208117 Date of Testing: 02/11/2011 <br /> Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 <br /> Facility Contact: MGR - MARIA Phone: (2 0 9) 830-0370 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Thuy <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: i c c License Number: 8016974 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> phil tite spill bucket 06/07/2012 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 SUP FILL ❑ ❑ ❑ El F-1 El El <br /> Spill Box 2 UNL FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ El ❑ ❑ ❑ ❑ <br /> El- <br /> El ❑ ❑ El ❑ ❑ ❑ ❑ <br /> 1:111:11 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ F-1 ❑ ❑ Eli ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> put in buckets with lids and take with me <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: 02/11/2011 <br />