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SWRCB, January 2002 0 • Rage 1. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. I. FACILITY INFORMATION FacilityName: CHEVRON 210997 (N-4693) DateofTesting: 02/07/2011 Facility Address: 1442A COLONY DR. , RIPON, CA, 95366 Facility Contact: PATTY Phone: ( 2 0 9) 599-0149 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): Muni 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: STEVEN WILLEMS Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester 9U q-, License Type: icc I License Number: 8016974 Manufacturer Manufacturer Training Component(s) Date Training Expires Phil Lite spill bucket 06/07/2012 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in drum and labeled and left onsite CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated �i}n(}t�his document are accurate and in full compliance with legal requirements Technician's Signature:�5� 0 r k �. Date: 02/07/2011 Component 9U q-, If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in drum and labeled and left onsite CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated �i}n(}t�his document are accurate and in full compliance with legal requirements Technician's Signature:�5� 0 r k �. Date: 02/07/2011