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SWRCB, January 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 (if 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: 11 / 13 / 2 0 0 7 Facility Address: 3725 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. ss Technician Conducting Test: MATTHEW HASLEY Repairs Made Credentials: Pass CSLB Licensed Contractor El SWRCB Licensed Tank Tester Secondary Pipe 1 reg License Type: A I License Number: 743160 ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires tanknology all 05/29/2009 E Secondary Pipe 2 plus ❑ ❑ ❑ E El 3. SUMMARY OF TEST RESULTS Component ss Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Secondary Pipe 1 reg ❑ ❑ 1:1 0 0 1:1 E Secondary Pipe 2 plus ❑ ❑ ❑ E El Secondary Pipe 3 sup El El F-1 El E El Piping Sump 1 ❑ ❑ ❑ ❑ 0 Piping Sump 2 F� El El El Piping Sump 3 X 1:1 El El Piping Sump 4 ❑ ❑ El El El El UDC 1/2 ❑ ❑ ❑ El El El El UDC 3/4 ` ❑ ❑ ❑ ❑ ❑ ❑ El - UDC UDC 5/6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 7/8 191❑ ❑ ❑ ❑ ❑ ❑ ❑ El 1:1 El IEl1 01El El El If hydrostatic testing was performed, describe what was done with the water after completion of tests: site to site 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: o44�Date: 11/13/2007