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• . • <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests (if oppl ieable), should be provided to the facility owner/operator for submittal to the local regulatory agenev. <br /> 1.FACILITY INFORMATION Facili ty ID: 01 <br /> Facilit Name: Shell Oil Products I Date of Testin : 6/10/2013 <br /> Facility Address: 3515 Navy Dr., Stockton, CA 95203 <br /> Facility Contact: Miguel Torres IPhone: 916-997-0053 r Initial f Repair Test <br /> Date Local Agency Was Notified Of Testing: 12/7/2012 F 6 Month r Other <br /> Name of Local Agency Inspector(if present during testing): Jeff Wong r Triennial <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Services <br /> Technician Conducting Test: Dan Luck <br /> Credentials: P CSLB Licensed Contractor r SW RCB Licensed Tank Tester F ICC UST Service Technician <br /> License T e:A B ASB C-10 HAZ I License Number:588098 <br /> Man ufactu rer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC Service Tech 5252167 9/29/2013 _ <br /> Franklin FuelinelNCON 0639483702 11/7/2014 <br /> 3.S UMMARY OF TEST RESU LTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Line#1 F r r r r r r r- <br /> Secondary Line 92 r r r r r r r r <br /> Sump Tank 42 F r r r r r r r <br /> r r r r r r r r <br /> r r r r r r r r <br /> r r r r r r r r <br /> r r r r r r r r <br /> r r r r r r r r <br /> r r r r r r r r <br /> r r r r r r r r <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test water left on site containment tank <br /> For any equipment capable of generating a print out of test results,you must attach a copy of the test reportto this <br /> certification F System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: X4 <br /> _ loe i/� Date: 6/10/2013 <br />