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SWRCB..anuarN 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This/r,rm is intended litr use hr contractors perlfwming periodic lesting of l ST secondary containment s.rctrms. l(ve the <br /> appropriale pages u/this fr,rm to repot!results 1,,r Ell/components les/ed The completed' ti+�ritlen rest procedtirev, and <br /> printouts front tests of applicable), should he prm-Wed to the fjedilY Owner li <br /> operator ,r suhmiltal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHELL —_- Date of Testing: 5-6-09 <br /> Facility Address: 4315 E. WATERLOO RD —_ -- <br /> Facility Contact: BILI. I Phone: f <br /> Date Local Agency Was Notified of Testing: 429109 <br /> Name of Local Agency Inspector 01 present chiring testing): _ GARRETT BACKUS - <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station`testing <br /> Technician Conducting Test: Heath A. McEver <br /> Credentials: CSLB Licensed Contractor S%k'RCB Licensed Tank- Tester <br /> r - _ <br /> License T,pe: Service Technician I.iccnse Number: 04-1677 <br /> Manufacturer Training <br /> Manufacturer ( mnponent(s) Date Training Expires <br /> �OPW SPILL BUCKETS 06/13/09 <br /> i <br /> 1 -IJ <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs ComI renew — P:r,a Fail , Not Repairs <br /> p — tested : Made _tested blade <br /> 87 FILL BUCKET X <br /> 91 FILL BUCKET X <br /> I <br /> i <br /> If hydrostatic testing was performed, describe.chat was done with the water atter completion of tests: <br /> I ransported water as test fluid <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> Tu Nie best of nit•Atiowledge,the fuer%s ed in 1hA document are accurate and in full compliance with legal requirement% <br /> Technician's Signature: -- Date: �' 1- - ' <br />