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`. WOO <br /> SWRCB,January 2002 Page 1 of 1 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written rest procedures, and printouts from tests <br /> (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:CHEVRON#98264(N-534) Datc of Testing: 2/25/2013 <br /> Facility Address:3775 N.TRACY BLVD ,TRACY,CA 95376 <br /> Facility Contact:MGR-PAT Phone:836-9422 <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:TANKNOLOGY INC. <br /> I echnician Conducting Test:Ryan Casey <br /> Credentials: r%—O CSLB Licensed Contractor F SWRCB Licensed Tank Tester <br /> License Type:ICC License Number:8178924 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Philtite Spill Bucket 4/29/2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box Tl supreme fill X <br /> Spill Box T2 plus fill X <br /> Spill Box T3 regular fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: VAC <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 /> i <br /> Technician's Signature: °`��`"+'� Date: 2/25/2013 <br /> WO:2309197 <br />