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Se; - 2S. 2003 10:54AM L*RVICES No , 2685 P. 2 <br /> SWRCa,January 2002 <br /> Page 1 of 2 <br /> Secondary Containment Testing Report Form <br /> 7h is form is intended for US8 by eadlraclors performing periodic testing of USrsecondary containment Sysrerns. Use the ro rials <br /> form Io report results for all eottlponents listed. 7$¢epmpl¢tadforrn,written test proceduret,and printouts from EYs1s(tfapplicabatePaould be <br /> provided to thefacility owner/operatorfor submittal to fhe local regulatory agency, <br /> t FACILITY INFORMATION <br /> FFa <br /> y Name:Lathrop Chevron <br /> y Address: 140 E Lathrop,Lathrop,Ca.85330 Date ofTesting: 4-29-03 <br /> y Contact: gob <br /> ocal ancy Was Notified ofTestng; 82of Local Agency Inspector(lf present during tasting), <br /> Z. TESTING CONTRACTOR INFORMATION <br /> Company Name:LC Services <br /> Technician Conducting Test:Michael Mullaly <br /> Credgntiais:CSLB Licensed Contractor <br /> License Type:AlHaz License Number.779267 <br /> Manufacturer muterTraJ g <br /> Component s) Date Training Expires <br /> moon TS-STS <br /> 1/22/2005 <br /> 3. SUMMARY OF TEST RESULTS <br /> ComponaM <br /> Not Papaw <br /> Pd55 Fail Tegtr-� Made Not flMadc <br /> t omponant Pess Fail TestedLtDG Dlap.7-8(R�ESTj � { < { <br /> JDQDlsp.11.12(RETEST < < { <br /> Piping R,un E7(Retest) <br /> Piping in 89(Retest) < <br /> < [ < { <br /> Plping stun 91(Retcsl) { < � < < <br /> < K <br /> C C < c <br /> < K C < <br /> C < < { <br /> < ! < < <br /> ! [ < < <br /> < C { K <br /> < < < < <br /> c < < < <br /> < < < < <br /> tf hydrostatic testing was performed,describe what was dove with the water after cOm ledon of tests: <br /> Water is returned back into test tonic. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE ICOR CONDUCTING THIS TEST <br /> .7'o the best of my Imowledge,the facts stated in chis document ark accurate and in full compllamce wilh legal requirememtt <br /> Technician's Signature; <br /> Date: <br />