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,SWRCB,January 2002 Page 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 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 209167 Date of Testing: 03/03/2010 <br /> Facility Address: 1234 E. YOSEMITE AVE @ SPRECKLES, 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): thuy tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a License Number: 743160 <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 Made <br /> Spill Box 1 SUP FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 UNL FILL -1 ❑ ❑ E ❑ ❑ <br /> D I ❑ 1 0 D ❑ El El El <br /> ❑ ❑ ❑ ❑ 0 0 F D <br /> El 0 0 El 0 0 <br /> El 0 0 0 0 0 ❑ 0 <br /> 0 0 0 El 0 0 0 <br /> 0 0 0 0 0 ❑ 0 0 <br /> 0 0 0 0 0 <br /> O 0 0 0 0 ❑ ❑ 0 <br /> 10Ell D 1 ❑ 1 10 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <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: P--L: Date: 03/03/2010 <br />