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09/18/2014 06:25 1209334"-'3 FLAGCITY CHEVRON PAGE 01/Fl5 <br />IMM8,44nuary 2002 Page _... of <br />Secondary Containment Vesting Report Form <br />This farm is Irtiertded for use by ctYttrcref0rs perfonniWp+c Modic testing of USS C011dwy e0"ta►` 't "e"s- Use the <br />,appropriate pag€s of thisf"", tv report results jar all ennrp(Awftfa tested The comlalekd form. written 41st pnlll dares. and <br />pr7rrtortts f—m tests Cf appliral k), should be provided to d w f rcilaty^ ow aloper ator for .,trlmrittal to the local regtrk"y09MfY <br />Fadfi Name: % �� ;" Date of <br />Fa6JAy address: <br />Fatrility comet" Phone: C) � � '"--'5 - <br />Date Local Agency Was Notified of Testing.:_.. f'k 0 <br />Nw a of)L,oc7J Agency ln5Pcotar (f present during testi: <br />2. 'r CSTINO CONT ,TOIt 0 RAI.sABON <br />Compe Name: -.1:'--, - —_ <br />Technician Conducting Test: <br />t,redentials: (x,8m Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type- I,xecnse Number: 4 7 <br />x,r..n..rars�nrar %4�lileill� <br />CEI �'iJPIC'A-p*N 0O�F� TE:CMI CAN I F•SPONSi LF- Teo It C ND'OC"£IN comp�1with <br />t �� requirp ncra� <br />7o the best ofmy kieorvill <br />�dXrlY' in t�tis tloctarrerrt au,e accrcrte f <br />Date: 7" 3 <br />Technician's Si e: <br />ct �attt� <br />3, <br />SUMMARY iJ1F�y4',�' <br />ft' <br />Component <br />Pg9S Fad N <br />TeWd <br />7�RESULTS <br />Awairs Comporpt <br />Made <br />rim, <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />❑ ❑ <br />❑Ery'A'det p <br />❑ <br />0 <br />dLl <br />❑ <br />{ i <br />W <br />❑ <br />❑ <br />n <br />❑ u u <br />❑ <br />_ <br />u <br />u <br />u <br />u <br />El <br />Or <br />3 <br />❑ <br />0 <br />0 <br />o <br />© <br />❑ <br />° <br />9 <br />Ll 0 El <br />13 <br />� <br />11 <br />Cl <br />Wl❑ <br />what M-6 daae <br />with the w4f er after completion of tests' <br />if lrydrostatac testing, wm p mibmedi d+eseribe <br />CEI �'iJPIC'A-p*N 0O�F� TE:CMI CAN I F•SPONSi LF- Teo It C ND'OC"£IN comp�1with <br />t �� requirp ncra� <br />7o the best ofmy kieorvill <br />�dXrlY' in t�tis tloctarrerrt au,e accrcrte f <br />Date: 7" 3 <br />Technician's Si e: <br />ct �attt� <br />