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SWRCB, Jarivary 2002 Page 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION FacilityName: SHELL # 136186 Date of Testing: 02/20/2008 Facility Address: 3725 N. TRACY BLVD TRACY, CA, 95376 Facility Contact: MANAGER Phone: (2 0 9) 835-7608 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 Fail Technician Conducting Test: SCOTT HOLMAN Pass Fail Credentials: Repair Made CSLB Licensed Contractor SWRCB Licensed Tank Tester ❑ ❑ License Type: Manufacturer I License Number: Manufacturer Training Component(s) Date Training Expires ❑ Spill Box 1 REG VAPOR x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU FILL ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 1 REG FILL F] ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 1 REG VAPOR x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU VAPOR E ❑ ❑ El El El❑ Spill Box 3 PRE FILL [fl ❑ F-1 El El El El ElSpill Box 3 PRE VAPOR El ElEl F-1 El F-1 F-1 ElSpill Box 4 DIE FILL ❑ ❑ ❑ El ❑ 1:1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑a❑ ❑❑❑❑ ❑ El El El El F] ❑ El EJ El El El El El❑ - ❑❑❑❑ ❑❑❑❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: , ae f- , Date: 02/20/2008