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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page I of 1 <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 (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 307709 jDate of Testing: 4/24/2013 <br />Facility Address: 10858 TRINITY PKWY , STOCKTON. CA 95219 <br />Facility Contact: MANAGER (N-7462-1-10) Phone: 209-952-2213 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): garrett backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: 17 CSLB Licensed Contractor <br />r SWRCB Licensed Tank Tester <br />License Type: a <br />ILicense Number: 743160 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2014 <br />F-- <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 />I ested <br />Repairs <br />Made <br />Spill Box T-2 premium fill <br />X <br />Spill Box Tl unleaded 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 />taken/recycled water trailer <br />CERTIFICATION OF TECIINICIAN 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: 4/24/2013 <br />WO: 2310197 <br />