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SWRCB,January 2002Page 1. <br /> econaMcontainment Testing eror For <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(rf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFO ! <br /> Facility Name: CHEVRON 209167 Date of Testing: 04/12/2006 <br /> Facility Address: 1234 YOSEMITE AVE MANTECA, CA, 95336 <br /> Facility Contact: MANAGER - KIM Phone: (2 0 9) 824-7433 <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: DOUGLAS HARTY <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Made <br /> Spill Box 1-91 0 ❑ ❑ ❑ ❑ ❑ ❑ El <br /> Spill Box 2-87 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ El ❑ <br /> ❑ El F] El El El ❑ ELI <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ MElM- <br /> ED El F-1 ❑ El El F-1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ o <br /> ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <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*nty knowledge, the fiicts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: y Date: 04/12/2006 <br />