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SWRCB,January 2002 13ECEIVED <br /> Secondary Containment Testing Report Form J 12 9 (� <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropr�2f4 <br /> pages of this form to report results for all components tested. The completed form, written test procedures, a if <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. TAL <br /> 1. FACILITY INFORMATION <br /> Facility Name:CHEVRON 201761 jDate of Testing: 1/14/2014 <br /> Facility Address: 1103 S.MAIN ST. PERMIT NUMB.N-3315,MANTECA,CA 95337 <br /> Facility Contact:MGR-MARIE Phone:209-825-0174 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):unknown <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: 17 CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:a ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/16/2014 <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 supreme fill X <br /> Spill Box T2 Regular 2 regular fill X <br /> Spill Box T3 Regular I regular fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> na <br /> CERTIFICATION OF TECIINICIAN 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: 1/14/2014 <br /> WO:2314893 <br />