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• • �, L <br /> SWRCB,January 2002 DEC 1 9RV7 of <br /> Secondary Containment Testing Report Form <br /> &Nn'IY R N11lEN AL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary c Ydt meQ{�SY� ih} <br /> appropriate pages ofthisform to report results for all components tested The completedform, writtc4t reft NInd <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tracy Boulevard Chevron I Date of Testing: 11/27/2017 <br /> Facility Address: 3775 North Tracy Boulevard,Tracy,Ca.95304 <br /> Facility Contact: Debbie Phone: (209)836-9422 <br /> Date Local Agency Was Notified of Testing: 10/9/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): Aaron Hang,EHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A I License Number: CSLB Lie.#341375/SWRCB Lie.#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell S stems Fill Riser Sump July 5, 2020 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Fill Riser Sump-Diesel ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ Cl ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ Li <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Fluid Supplied and recovered for reuse. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in thisdocumentare accurate and in full compliance with legal requirements <br /> Technician's Signature: ailsf- e!/, Date: November 27,2017 <br />