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1 0 0 <br />SWRCB, January 2002 RECEIVED Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use thd''a#pr rtate` 0- 14 <br />pages of this form to report results for all components tested. The completed form, written test procedures, and p ' t &om tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />RONMENTAL <br />1_ FACII.ITV INFORMATION -. <br />MNT <br />Facility Name: CHEVRON 208118 N-4087-1-3 Date of Testing: 2/20/2014 <br />Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA 95212 <br />Facility Contact: MANAGER Phone: 209-477-3699 <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: Timothy Elebeck <br />Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: ICC ILicense Number: 8001435 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />PHIL TITE SB 3/22/2015 <br />3_ fi1iMMARV OF TFST RFS111,TS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box Tl supreme fill <br />X <br />Spill Box T2 regular fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER WAS TAKING AS TEST WATER <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: `L—° ""° 9 f Jc1C Date: 2/20/2014 <br />WO: 2315865 <br />