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'LINA( <br /> Page of <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 /> Facility Name: Marada Chevron Date of Testing: 3/13/06 <br /> Facility Address: 10878 N.Hwy 99 <br /> Facility Contact: Ali Yasmin Phone: 707-747-2955 <br /> Date Local Agency Was Notified of Testing: 3/11/06 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CGRS Inc,5444 Dry Creek Rd,Sacramento CA 95838 <br /> Technician Conducting Test: Brian Green <br /> Credentials: 4 CSLB Licensed Contractor J SWRCB Licensed Tank Tester <br /> License Type: Haz-A #803616 1 License# 03-1645 <br /> Manufacturer Training <br /> Manufacturer Com nent s) Date Training Expires <br /> Va orless Mfg Barrett Model 309 Sump Tester 4/29/06 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component Pass Fail Not Repairs <br /> Component Pass Fail Tested Made p Tested Made <br /> 87 Unleaded Secondary Pipe 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 89 Unleaded Plus Secondary J ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Premium Secondary Pipe 4 [1 El El ❑ ❑ ❑ ❑ <br /> Diesel Secondary Pipe 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Unleaded Turbine Sump 4rEl <br /> 11 El El ❑ F1 <br /> 89 Unlead Plus Turbine Sump ,J El ❑ ❑ El El ❑ <br /> 91 Premium Turbine Sump J E) El ❑ ❑ El 11Diesel Turbine Sump J El El El ❑ El 11❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ i ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water is <br /> filtered, processed and removed from site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefac ated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: - Date: ? �� <br />