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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of I <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, andprintautskv tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION RECEIVED <br />Facility Name: CHEVRON 307709 jDate of Testing: 4/21/2014 <br />Facility Address: 10858 TRINITY PKWY , STOCKTON, CA 95219 <br />Facility Contact: MANAGER (N-7462-1-10) Phone: 209-952-2213 <br />ILZ <br />Date Local Agency Was Notified of Testing: ktA5Z =-,q <br />Name of Local Agency Inspector (if present during testing): Stacy <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: r i CSLB Licensed Contractor <br />rl SWRCB Licensed Tank Tester <br />License Type: a <br />License Number: 743160 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2014 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box TI unleaded fill <br />X <br />Spill Box T-2 premium fill <br />X <br />Spill Box T-3 diesel fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />n/a <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, <br />,tt-hhee facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: JvDate: 4/21/2014 <br />WO: 2316672 <br />i1TAL <br />ENT <br />