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0 <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor 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 applicable), should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATIONFacilit ID: 01 <br /> FacilityName: Shell Oil Products DateofTestin : 12/11/2012 <br /> Facility Address: 3515 Navy Dr., Stockton, CA 95203 <br /> Facility Contact: Miguel Torres I Phone: 916-997-0053 r Initial F Repair Test <br /> Date Local Agency Was Notified Of Testing: 12/7/2012 r 6 Month r Other <br /> Name of Local Agency Inspector(if present during testing): Stacy Rivera r Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Services <br /> Technician Conducting Test: John Cascio <br /> Credentials: F CSLB Licensed Contractor r SWRCB Licensed Tank Tester F ICC UST Service Technician <br /> License Type: A B ASB C-10 HAZ I License Number:588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC Service Tech 5252163 9/29/2013 _ <br /> Incon 6929323704 11/5/2014 <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Sump#2(Tank) r r r r r r r r <br /> Line#1 F r r r r r r r <br /> Line#2 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 /> r r r r r r I r I r <br /> If hydrostad c testing was performed,describe what was done with the waterafter completion of tests: <br /> Test water was put into Oil Water Seperator on site. <br /> For any equipment capable of generating a print out of test results,you must attach a copy of the test report to 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: Jam_ C".-CZ Date: 12/11/2012 <br />