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0 <br /> SW[W137January2002 Page of'_ <br /> Secondary Containment Testing Report Form <br /> This Jo,•,n is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components rested The completed form, written test procedures, and <br /> printatuts,from tests(if applicable), should be provided to the facility ownerloperator•for submitlal to the local regulatory agent. <br /> I. FACILITY INFORMATION <br /> Faeil t� Name: Lower Sacramento Chevron Date of'Iesting: 4-26-12 <br /> Facility �...__..._ ---- ... _ <br /> Address: 8660 Lower Sacramento Road,Stockton Ca 95210 <br /> Facility Contact:. Kamal Kapoor Phone: 209-477-2844 <br /> Date Local Agency Was Notified of`testing: 4/24/12 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> ... <br /> Technician Conducting Test: Gabe Garcia <br /> ___........... <br /> j Credentials: x CSI B Licensed Contractor SWRCB Licensed Tank Tester — <br /> h �' <br /> 1-icenseType: A License Number: 811471 CCC ff 5281.582 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Lires <br /> 3. SUMMARY OF TEST RESULTS1 N t Repairs: Not Repairs <br /> Component Pass !Fail Tested Made Component Pass Fail ail Made <br /> �nt�ualr 1 - Super <br /> x IJDC 1-2 x <br /> ,Annular 2 -Plus xi s IJDC 3-4 x <br /> ' - - ---------- <br /> Annular i <br /> 3 - Regular x ( UDC 5-6 x <br /> I Ane 1 Super x UDC 7-8 x <br /> Line 2- Plusx = x ., <br /> Line 3- Regular x l x L <br /> T.__.. _ . . -.....�. _.._...__ <br /> ump 1 -Super x <br /> h <br /> Sum J —Plus l; i <br /> lut7Ap 3 - Regular x <br /> I - <br /> 3 ._ <br /> t i <br /> — �— <br /> _ da <br /> lf'hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of n y knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ' 'G� / Date <br />