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RECEIVE® <br />t0k <br />APR 29 2018 <br />SWRCB, January 2002 Page of <br />Secondary Containm�t 0 O�� rt Form <br />.! �'H C?F..n M! _ftlT <br />This form is intended for use by contractors performing periodic testing of T secondary containment systems. Use the <br />appropriate pages of this formr to report results for all components tested. The completed form, written lest procedures, and <br />printouts from tests (if applicable), should beprovided to the facility owner/operator• for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Waterloo Shell Date of Testing: 4/17/2018 <br />Facility Address: 4315 Waterloo Rd Stockton Ca 95215 <br />Facility Contact: Rupi Padda Phone: 209-814-0300 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (fpresent during testing): Aaron Hang <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Elite IV Contractors <br />Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />Technician Conducting Test: Fred B <br />X <br />Credentials: X CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s)) Date Training Expires <br />91 STP Sump Secondary <br />X <br />87 Secondary Vacuum <br />X <br />91 Secondary Vacuum <br />X <br />Vent Secondary Vacuum <br />X <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />87 Fill Secondary <br />X <br />91 Fill Secondary <br />X <br />87 STP Sump Secondary <br />X <br />91 STP Sump Secondary <br />X <br />87 Secondary Vacuum <br />X <br />91 Secondary Vacuum <br />X <br />Vent Secondary Vacuum <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Performed secondary brine communication test on all fill sumps and STP sumps, 87 <br />failed communication test <br />Verified vacuum on secondary product line. <br />CERTIFICATIOPYOF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, *efacts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: <br />Date: <br />