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SWRCB, January 2002 Page 1. <br />Secon Containment Testing Reort 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 />FacilityName: CHEVRON #208117 <br />1 DateofTesting: 03/14/2006 <br />Facility Address: 755 S. TRACY BLVD , TRACY, CA, 95376 <br />Facility Contact: MGR - MARIA <br />Phone: (209) 830-0370 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />CONTRACTOR2. TESTING O <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />DOUGLAS HARTY <br />MM <br />Credentials: <br />❑ <br />CSLB Licensed Contractor EI <br />SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Spill Box 2-87 <br />�����Mmwm <br />Component <br />MM <br />Wo Mara <br />Spill Box 1-91 <br />Spill Box 2-87 <br />MME <br />M� <br />MW <br />mmmm�� <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 />03/14/2006 <br />Technician's Signature:- J Y Date: <br />