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SWRCB, January 2002 <br />Page f <br />Secondary Containment . T e tin e: ort Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages gl`this form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (ij*applicable,), should be provided to the facility ownerloperator fpr submittal to the local regulatory ra eney. <br />1. FACiMY INFORMATION <br />Facility Marne; SMK Collier Road Chevron mate of Testing: tune ,till 1 <br />Facility Address: 25651 North Highway 99, Acampo, Ca, 95220 <br />Facility Contact: "Pony Singh Phone: (2ii ) 333-1740 <br />Date Local Agency Was Notified of Testing:� 12t2014, by Afford -A -Test <br />Name of Local Agency inspector (ifpresent dewing testing): <br />Component <br />Annular Tank #1 <br />Annular Tank #2 <br />Annular Tank #3 <br />Secondary Pipe #1 <br />Secondary Wipe #2 <br />S condary Pit)eV #3 <br />F <br />i ylr i� u <br />Pass Fail T <br />E <br />X <br />x <br />x <br />io <br />steel <br />Piping Sump #3 _j <br />Repairs <br />bade <br />Component Pass <br />_ <br />Pail <br />Not <br />Tested <br />Repairs <br />Made <br />C`'13ipener <br />Sump #7&8 <br />it <br />F-', <br />Dispenser Sump #9&10 X <br />Dispenser Stamp #1 12 X <br />0 <br />D <br />0 <br />Fill Riser Sump #1 x <br />_ ["'1 <br />0 <br />11 <br />Fill Riser Sump #2 <br />� <br />Fill Miser Sump #3x0 <br />0 <br />0 <br />C.A <br />1...;.... <br />..,l <br />is <br />0 <br />!...� <br />i....< <br />0 <br />n <br />11 <br />0 <br />0 <br />m <br />JUN 1 201 n <br />n <br />LEJ <br />n <br />11 <br />01 <br />0 <br />n <br />ENVIRONMENTAL H LT <br />If hydrostatic testing was performed, describe what was done with the water dMrt i' l5ktib►r VV`iests: <br />Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing, <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stater) in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: � � � . _ Lute: ,-4-,ZQ. <br />