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a • ��� <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form NOV 0 6 2009 <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment systems. Usee tthhe <br /> JK <br /> appropriate pages of this form to report results for all components tested. The completed form, writte&WAR6jN <br /> 111�Q <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal tot epmTeRvIefficy <br /> 1. FACILITY INFORMATION <br /> Date of Testing: 10/27/09 <br /> Facility Name: Shell Terminal <br /> Facility Address: 3515 Navy Drive <br /> Facility Contact' Gerald Phone: <br /> Date Local Agency Was Notified of testing; <br /> Name of Local Agency Inspector(if present 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#5252406 <br /> Manufacturer Training Date Training Exp' <br /> Manufacturer Component(s) <br /> 3. SUMMARY OF TEST RESULTS <br /> Pass Fail Not Repairs <br /> Pass Fail Not Repairs Component Tested Made <br /> Component Tested Made <br /> Line I x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 1 (transition) x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 2 (tank) x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Space(tank 9 slope) x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ El El 11 ❑ <br /> ❑ ❑ <br /> i ❑ ❑ ❑ ❑ ❑ <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 full compliance with legal requirements <br /> Technician's Signa <br /> Date: � 7/� `7 <br />