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x. <br /> t <br /> SWRCB,January 2002 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.FACILITY INFORMATION <br /> Facility Name:CHEVRON#96171 (N-621-1-3) Date of Testing: 1/6/2012 <br /> Facility Address:6633 PACIFIC AVE ,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SUE LYNN Phone:477-4294 <br /> Date Local Agency Was Notified of Testing:12/27/2011 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steven Willems <br /> Credentials: W CSLB Licensed Contractor r—SWRCB Licensed Tank Tester <br /> License Type: icc License Number:8016974 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> phil tite spill bucket 6/6/2012 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box supreme SUPREME F X <br /> Spill Box regular I REGULAR F X <br /> Spill Box regular 2 REGULAR F X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests:put in buckets with lids and <br /> take with me <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the11fallcts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �J Date: 1/6/2012 <br />