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W. � 1j <br /> SWRCB,January 2002 Page of_ <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by corth-actors 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 firom tests (ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Shell Oil Terminal 1FDate of Testing: 10/2/12 <br /> Facility Address: 3315 Navy Drive, Stockton Ca <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC H 5252406 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Space X <br /> Sualp I X <br /> Sump 2 X <br /> Line 1 X <br /> Line 2 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <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 fill compliance with legal requirements <br /> Technician's Signature:-P/- ;D"-a& _ Date:_10-2-12 <br />