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SWRCB,January 2002 Secon arY Containment Testing Reort Form <br /> Page 1. <br /> This form 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 tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON #99840 Date of Testing: 03/13/2 00 6 <br /> Facility Address: 4344 WATERLOO RD , STOCKTON, CA, 95210 <br /> Facility Contact: MANAGER Phone: (20 9) 931-2186 <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: DOUGLAS HARTY <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 /> �4 <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 1-91 ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> Spill Box 2-87 ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ a ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ❑ I Ell ❑ I ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ <br /> ® Eli ❑ ❑ E] El <br /> ❑ ❑ ❑ ❑ 1 ❑ o ❑ o <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 best of my knowledge, the facts stated <br /> -yin this document are accurate and infill compliance with legal requirements <br /> � 03/13/2006 <br /> Technician's Signature: ;:_ Date: <br />