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SWRCB,January X002 Page 1. <br /> Secondat Containment Testing Rep 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 /> Facility Name: CHEVRON 208118 N-4 0 8 7-1-3 Date of Testing: 02/24/2011 <br /> Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA, 95212 <br /> Facility Contact: MANAGER Phone: (2 0 9) 477-3699 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: TIMOTHY ELEBECK <br /> Credentials: CSLB Licensed Contractor El SWRCB Licensed Tank Tester <br /> License Type: ICC License Number: 8001435 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> PHIL TITE SPILL BUCKET 08/11/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> ss <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 SUP FILL E ❑ 0 ❑ 1:1 El El E <br /> Spill Box 2 UNL FILL X ❑ ❑ <br /> ❑ ❑ ❑ I ❑ ❑ <br /> El El El El <br /> E El E <br /> El 11-1 El <br /> ❑ I ❑ ❑ 1 ❑ 1:11 Eli ❑ 1 ❑ <br /> El F-1 El El <br /> El El <br /> El ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ell Ell El El Ell F-1 F-1 10 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WATER WAS PUT IN WASTE DRUM <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: <br /> � Date: 02/24/2011 <br />