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SWRCB, January 2002 0 is <br />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 />FacilityName: CHEVRON #208117 <br />Date of Testing: 04/04/2007 <br />Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MGR - MARIA <br />Phone: (2 0 9) 830-0370 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: <br />RHOME DESBIENS <br />Component <br />Credentials: <br />rem, .9 <br />CSLB Licensed Contractor <br />D <br />SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />I License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />x 1 SUP FILL <br />Spill BoMMMM <br />■ <br />■ <br />■ <br />■ <br />MIMMM <br />Component <br />Component <br />rem, .9 <br />Spill Box 2 UNL FILL <br />MIM <br />x 1 SUP FILL <br />Spill BoMMMM <br />■ <br />■ <br />■ <br />■ <br />MIMMM <br />MIME <br />MIMM� <br />MEMIMMM <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 />Technician's Signature:? Date: 04/04/2007 <br />