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SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> Tluis form is untended for use bV contractors performing periodic:testing of UST secondavy containment sv_steuns. Use the <br /> appropriate pages of this forrn to report results for all components tested. The cornpleted.fornu, written test procedures, and <br /> u <br /> pruouts from tests(rf applicable), should he provided to the.facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: USA # 03696 (CHEVRON BRAND NAME) Date of Testing: 05/30/2006 <br /> Facility Address: 2448 W KETTLEMAN LN @ LOWER SACRAMENTO RD, LODI, CA, 95242 <br /> Facility Contact: MGR - DAVE Phone: (2 0 9) 3 6 9-3 12 4 <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: HEATH MCEVER <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 91 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 87 ❑ X❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> Spill Box 89 ❑ X❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ , 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ F-11 ❑ ❑ EllI ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest of'nuv knowledge, the fltets stated in this docuurnent cure accurate and in full compliance with legal requirements <br /> Technician's Signature: / Date: 05/30/2006 <br />