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SWRCB,7anuary 2002 Page 1. <br /> Secondary Containment Testing Report For <br /> This form is'intendedfor use by contractors performingperiodic testing of USTsecondary 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 frf applicable),should be provided to the facility owner/operator for submittal to the local regttlatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 201761 Date of Testing: 04/04/2006 <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: RAYMOND SIMMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Typ I License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> / 1 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Spill Box 1 -- <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 ❑x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> F-1 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑1 F-11 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 nay knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: A, t-� Date: 04/04/2006 <br />