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SWRCB, January 2002 <br />0 <br />0 <br />Secondary Containment Testing Report Form <br />Page I of 1 <br />This forma is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br />Of applicable), should he provided to the facility ownerioperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 210997 (N4693) <br />Date ol'Testing: 2/2/2012 <br />Facility Address: 1442A COLONY DR. . RIPON. CA 95366 <br />Facility Contact: PATTY Phone: 599-0149 <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 />Technician Conducting Test: Joey Mesa <br />Credentials: rv— CSLB Licensed Contractor <br />r swkCB Licensed Tank Tester <br />License Type: ICC SERVICE TECH. License Nu ber: 5259458 -UT <br />Manufacturer <br />lianufactrnrr Trainin{� <br />Component(s) Date Training I:yiiru <br />OPW <br />SPILL BUCKET 9/15/2013 <br />3. SUMMARY OF TEST RESULTS <br />k, M11 <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 full compliance with legal requirements <br />Technician's signature: _ii t�� Date: 2/2/2012 <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 full compliance with legal requirements <br />Technician's signature: _ii t�� Date: 2/2/2012 <br />