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E <br />SWRCB, January 2002 <br />Page 1 of 1 <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. FAC'II,ITV INFORMATION <br />Facility Name: CHEVRON 208118 N-4087-1-3 Date of Testing: 2/23/2012 <br />Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA 95212 <br />Facility Contact: MANAGER Phone: 477-3699 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): GARRET <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Spill Box T 1: SUPREME F <br />Spill Box T2: REGULAR F <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: TAKEN IN WATER TRAILER. <br />CERTIFICATION OF TECHIVICIAN 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: e$ Date: 2/23/2012 <br />