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0 <br /> SWRCB,January 2002 Page 1 of I <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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:CHEVRON 201761 Date of Testing: 1/18/2013 <br /> Facility Address: 1103 S.MAIN ST. PERMIT NUMB.N-3315,MANTECA,CA 95337 <br /> Facility Contact:MGR-MARIE Phone:825-0174 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):muni <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steven Willems <br /> Credentials: W CSLB Licensed Contractor F SWRCB Licensed Tank Tester <br /> License Type:tanknology ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> phil tite spill bucket 10/16/2014 <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 1 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: 1/18/2013 <br /> WO:2308165 <br />