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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 #208117 Date of Testing: 02/16/2010 <br /> Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 <br /> Facility Contact: MGR - MARIA Phone: (2 0 9) 830-0370 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DANIEL ROLLINS <br /> Credentials: CSLB Licensed Contractor El SWRCB Licensed Tank Tester <br /> License Type: ICC I License Number: 8011610 <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 � El El E] 1:1 1:1 ❑ El <br /> Spill Box 2 UNL FILL x ❑ ❑ ❑ F-1 ❑ ❑ <br /> El <br /> 0 El El El El <br /> F1 El El El <br /> El F-1 E <br /> 0 E El F� F1 El <br /> El F-1 F-1 El El El El <br /> El El 0 F1 E] <br /> El ❑ 1:1 El El <br /> El El F� E El <br /> 1:11 El 1 01 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT ONSITE <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 /> 0 2/16/2 010 <br /> Technician's Signature: b �� Date: <br />