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SWRCB, January 2002 . Secondf y Containment Testing Report Form Page 1. This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the apPropriatepages of this form to report results for all components tested. The completedform, written testprocedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON 91452 (N-618) Date of Testing: 01/08/2008 Facility Address: 334 E. MAIN ST ® HWY 99, RIPON, CA, 95366 Facility Contact: DEALER - MOHINDER f Phone: (209) 599-2313 Date Local Agency Was Notified of Testing: / / Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Pass Technician Conducting Test: HEATH MCEVER Repairs Made Credentials: ❑ CSLB Licensed Contractor F-1 SWRCB Licensed Tank Tester Repair Made License Type: SERVICE TECH License Number: 5236756 -UT ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires PHIL-TITE SPILL BUCKETS 06/13/2008 ❑ E:1 Spill Box 2 PLU FILL Spill El 1:1 1:1 1:1 ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 1 SUP FILL El ❑ ❑ ❑ ❑ ❑ ❑ E:1 Spill Box 2 PLU FILL Spill El 1:1 1:1 1:1 ❑ ❑ ❑ - ❑ Spill Box 3 UNL FILL El ❑ ❑ ❑ ❑ ❑ ❑ I Eli r❑ E IEl El El El El El El El El El El El El Ej El El El El � � El El I El El El � El ❑ ❑ ❑ ❑ ❑ tEE:1 El E El El El El El El Q El El El El El El If hydrostatic testing was performed, describe what was done with the water after completion of tests: LEFT IN DRUM ON SITE CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Z�� Date: 01/08/2008