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9 <br />0 <br />Page of <br />PINNACLE 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 fonn, 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 />Facility Name: Lathrop Chevron I Date of Testing: 1/6/2014 <br />Facility Address: 140 E Lathrop Rd., Lathrop, Ca. 95330 <br />Facility Contact: Owner -Jesse I Phone: (209-982-5005) <br />Date Local Agency Was Notified of Testing: 1/2/2014 <br />Name of Local Agency Inspector (if present during testing): Thuy Tran <br />2. TES'T`ING CON'T'RACTOR INFORMATION <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Jeff Conger <br />ICC # 1081782 UT <br />Credentials: 0 Licensed Contractor <br />�]x, Licensed Tank Tester Incon Level 4 Sump Test System <br />License Type: CSLB 894932 <br />License Number: SWRB 90-1116 6458613703 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />INCON <br />Sump Test System 05/19/2015 <br />Dispenser#I 1-12 UDC WIMMM <br />3. SUMMARY OF TEST RESULTS <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: " `� Date: 1/6/2014 <br />91 Secondary Fuel Lie <br />Dispenser#I 1-12 UDC WIMMM <br />WW00 <br />��0© <br />mwm0 <br />��00 <br />mmm0 <br />mwm0 <br />=MW= <br />��0© <br />mm0© <br />��00 <br />—MM00 <br />��00 <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: " `� Date: 1/6/2014 <br />