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SWRCB, January 2002 Page 1. <br />is <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: CHEVRON 201761 <br />Date of Testing: 02/03/2009 <br />Facility Address: 1103 S. MAIN ST. , MANTECA, CA, 95337 <br />Facility Contact: MGR - MARIE <br />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 />CONTRACTOR2. TESTING INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />STEVEN WILLEMS <br />Credentials: <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Box 2 REG FILL <br />!Spill Box 3 SUP FILL <br />3. SUMMARY OF TEST RESULTS <br />1 110 W-33 t <br />Box 2 REG FILL <br />!Spill Box 3 SUP FILL <br />000' <br />-��OOi <br />000 <br />,1��00' <br />0000-„-��DOi <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: 02/03/2009 <br />