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SWRCB,January 2002 Page 1. <br /> Secondfy Containment Testing Reffit 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 /> FacilityName: CHEVRON 201761 Date of Testing: 02/05/2007 <br /> Facility Address: 1103 S. MAIN ST. , MANTECA, CA, 95337 <br /> Facility Contact: MGR - MARIE Phone: (2 0 9) 825-0174 <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: CHRISTIAN ELIAS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I License Number: <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 REG FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PLU FILL X ❑ ❑ ❑ ❑ ❑ 1:1 ❑ <br /> Spill Box 3 SUP FILL I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El I El El El El <br /> El El Eli El F-1 El <br /> E F1 El E El <br /> El M F� El F� ❑ El El <br /> ❑ ❑ ❑ El ❑ ❑ ❑ El- <br /> El <br /> El El ❑ El ❑ El El El <br /> El ❑ ❑ El ❑ F-1 F-1 El <br /> El F-1 ❑ El <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 /> Vjr� <br /> Technician's Signature: Date: 02/05/2007 <br />