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SWRCB,January 2002 OCT 2 0 5 <br /> Secondary Containment Testing Report Form ``'' ENTAL <br /> This form is intendedjor use by contractors performing periodic testing of UST secondary cantainmen lhj.Tu nr 61 Anrr <br /> appropriate pages of this form to report results for all components tested. The cornpletedform, written te,5�1�Y�TA%s, anc! <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 Facili ID:01 <br /> Client Name: Shell Oil Products Date of Testing: 2015-09-25 <br /> Facility Address: 3515 Navy Dr. City: Stockton State: CA Zi Code: 95203 <br /> Facility Contact: Miguel Torres Phone: 916-371-6911 ❑ Initial ❑Re air Test <br /> Date Local Agency Was Notified of Testing: 2015-09-22 ❑ 6 Month ❑Other <br /> Name of Local Agency Inspector(ifpresent during testing): Staci Rivera 0 Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services <br /> Technician Conducting Test: Victor Guerrero <br /> Credentials: ❑X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester Q ICC UST Service Technician <br /> License Type: A B ASB C-101-1.%Z License Number: 588093 <br /> Manufacturer Trainini* <br /> Manufacturer Component(s) _ Date Trainin Ex fres <br /> ICC UST Service Tech. 8017001-UT 2017-06-09 <br /> Franklin Fueling Incon TS-STS 3581763704 2017-04-23 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Annular IK ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line Secondary#1 x❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line Secondary#2 (K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Slop Tank Sump ❑ m x❑ ❑ ❑ ❑ ❑ ❑ <br /> Lane 3 Sump ❑x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 Ell <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> All test water was left 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 certification. <br /> ❑X System printout attached. <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 Signature: <br /> V � oma' Date: 2015-09-25 <br />