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f 4 <br /> SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <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 #201383 (N-2515) DateofTesting: 02/11/2010 <br /> Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW, TRACY, CA, 95376 <br /> Facility Contact: MGR - HELEN Phone: (2 0 9) 836-3181 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): THUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DANIEL ROLLINS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC License Number: 801161OUT <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 1 SUP FILL F-1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PLU FILL ❑ ❑ ❑ ❑ ❑ ❑ El <br /> Spill Box 3 REG FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El F-1 01 <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> El ❑ El El <br /> EJ F� F-1 El 1:1 E] El <br /> ❑ ❑ ❑ ❑ ❑ <br /> Ell F-1 El El F-1 El <br /> El ❑ F] El <br /> El 0 1:1 El <br /> Ell D I El ❑ ❑ ❑ 10 <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 in this document are accurate and in full compliance with legal requirements <br /> l <br /> Technician's Signature: � t L �� Date: 02/11/2010 <br />