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SWRCB,January 2002 <br /> RECENE - <br /> Secondary Containment Testing Report Form <br /> F_3 2 7 2014 <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 test procedures, and@jptgglyi4'/yyrtQ`t;(if�T^t <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. ENVV�HEALIT`SHVDIEVPIAVIRtTME1NAL <br /> 1. FACILITY INFORMATION <br /> Facility Name:CHEVRON#98264(N-534) Date of Testing:2/21/2014 <br /> Facility Address:3775N.TRACY BLVD ,TRACY,CA 95376 <br /> Facility Contact:MGR-PAT Phone:209-836-9422 <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 /> Technician Conducting Test:Darren Sciume <br /> Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:CA Tank Tester License Number:09-1733 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> FFS Phase 1 components 5/14/2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box TI supreme fill X <br /> Spill Box T2 plus fill X <br /> Spill Box T3 regular till X <br /> If h%dro,latic tcstine was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TFBS 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: Yl�i Date: 2/21/2014 <br /> WO:2315868 <br />