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yEQ IVED <br /> Elite IV Contractors MAR 9P&8 oft <br /> Secondary Containment Testing Report ForMtRW f1A1 jj , <br /> EA <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. �de <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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name Tracy Blvd Chevron Date of Testing: 3/12/2018 <br /> Facility Address: 3775 Tracy Blvd Tracy Ca 95376 <br /> Facility Contact: Debbie 209407-9743 Phone:209-407-9743 <br /> Date Local Agency Was Notified of Testing:3/8/2018 <br /> Name of Local Agency Inspector(if present during testing): Betty Ho <br /> TA0249501 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Elite IV Contractors <br /> Technician Conducting Test:Joe Bartholdi <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC California UST Service Technician License Number: <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Trainin Ex ires <br /> Caldwell <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> P Tested Made Component Pass Fail Tested Made <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this cun{tare accurate and in full compliance with legal requirements <br /> Technician's Signature: J// Date: l/ U <br />