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SWR(tB, January 2002 Page 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 <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 307709 <br />Date of Testing: 10/02/2009 <br />Facility Address: 10858 TRINITY PKWY STOCKTON, CA, 95210 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 952-2213 <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 />Pass <br />Technician Conducting Test: <br />JARROD COOKE <br />Repairs <br />Made <br />Credentials: <br />Pass <br />CSLB Licensed Contractor <br />Not <br />Tested <br />SWRCB Licensed Tank Tester <br />Fill Riser 1 UNL <br />License Type: a <br />I <br />License Number: 743160 <br />0 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/18/2011 <br />0 <br />0 <br />0 <br />0 <br />Ell <br />0 <br />0 <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 />Repair ss <br />Made <br />Fill Riser 1 UNL <br />a <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Ell <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />El <br />El <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />- <br />El <br />0 <br />El <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />- <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Ell <br />Di <br />0 <br />0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water <br />CERTIFICATION OF TECIINICIAN 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: 10/02/2009 <br />