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SWRCB,January 2002 Page 1 of I <br /> Secondary Containment Testing Report Form RECEIVED <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, andprintoFEROO&sf�(�i,'�. <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION ENVIRONMENTAL <br /> Facility Name:CHEVRON#201383(N-2515-1-1) jDate of Testing:2/13/2014 <br /> Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW,TRACY,CA 95376 <br /> Facility Contact:MGR-HELEN Phone:209-836-3181 <br /> Date Local Agency Was Notified of Testing:2/13/2014 <br /> Name of Local Agency Inspector(if present during testing):Thuy Tran Rehs <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials: ' CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:A License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> phill tite spill buckets 2/5/2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box Tl supreme fill X <br /> Spill Box T2 plus fill X <br /> Spill Box T3 regular fill X <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 /> Technician's Signature: Date: 2/13/2014 <br /> WO:2315851 <br />