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SWRCB, January 2002 <br />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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: CHEVRON 307709 <br />Date of Testing: 09/15/2009 <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): N/A <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />M <br />Technician Conducting Test: <br />BRYAN KEYS <br />I I - <br />Credentials: <br />CSLB Licensed Contractor <br />1fl <br />SWRCB Licensed Tank Tester <br />License Type: <br />I <br />License Number: 07-1735 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />PHIL-TITE <br />PHASE 1 <br />12/19/2009 <br />00m0 <br />��00 <br />3. SUMMARY OF TEST RESULTS <br />I Component <br />iL <br />M <br />M� <br />I I - <br />00m0 <br />��00 <br />0mm0wmmm <br />��00 <br />wmmm <br />��00 <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <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 document are accurate and in fidl compliance with legal requirements <br />Technician's Signature: / Date: 09/15/2009 <br />