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SES my of San Die <br /> DEPARTMENT NVIRONMENTAL HEALTH-HAZARDOUS ERIALS DIVISION <br /> P.O.BOX 129261,SAN DIEGO,CA 92112-9261 <br /> (619)338-2222 FAX(619)338-2377;1-800-253-9933 <br /> http://www.sdcounty.ca.gov/deh/hmd/forms_hmd.htmi <br /> cc UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT <br /> TESTING REPORT FORM <br /> This form is intended for use by contractors performing initial and periodic testing of UST secondary containment systems. Use the <br /> propriate ages of this form to report results or all components tested. The completed form, written test procedures, and printouts <br /> afrom tests(inapplicable), must be provided to t e facility owner/operator for submittal to the County of San Diego Department of <br /> Environmental Health Hazardous Materials Division UST Group. <br /> Permit Number: Plan Check Number: <br /> FACILITY INFORMATION <br /> Facility Name:CHEVRON 209167 Date of Testing: 04/11/2007 <br /> Facility Address: 1234 YOSEMITE AVE , MANTECA, CA, 95336 Test Type: <br /> Facility Contact: MANAGER - KIM Phone: (2 0 9) 824-7433 Initial <br /> Date Local Agency Was Notified of Testing: / / ❑ 6 months <br /> Name of Local Agency Inspector(if present during testing): 36 months <br /> TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: ROBERT SANTOS <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 2 UNL FILL FRI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 1 SUP FILL x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El F-1 El E El El El <br /> El F-1 F1 <br /> El- <br /> El El El E El El E <br /> El F <br /> ❑ E] I ❑ F-1 I ❑ Ell ❑ ❑ <br /> El El El El El El EJ <br /> ❑ ❑ I ❑ ❑ 1 0 0 ❑ El- <br /> El <br /> El ❑ F] F] El El 1:1 El <br /> El El El El El El <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 /> For all testing equipment capable of generating a print out of test results,you must attach a copy of the <br /> test report to this certification. F-] System print ut attached <br /> Technician's Signature: 0 Date: 04/11/2007 <br /> DEHM:HM-9169(09/04) <br />