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SWRCB, Jwauary 2002 .0 • 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 Facility Name: SHELL # 136186 Date of Testing: 07/13/2007 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. Pass Technician Conducting Test: MATTHEW HASLEY Repairs Made Credentials: Pass CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester Secondary Pipe 1 reg License Type: X❑ License Number: Manufacturer Manufacturer Training Component(s) Date Training Expires tanknology all 05/29/2009 a Ell El 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Secondary Pipe 1 reg ❑ X❑ Secondary Pipe 2 plus a Ell El Secondary Pipe 3 sup ❑ rL±-J' ❑ ❑ Secondary Pipe 4 dsl X 1:1 ❑ UDC 3/4 El ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 9/10 El ❑ ❑ ❑ ❑ ❑ El ❑ UDC 13/14 E1 ❑ ❑ ❑ ❑ ❑ ❑ UDC 15/16 El ❑ ❑ ❑ ❑ ❑ 1:1 ❑ E El El El El El El El El El El El El ED 1:1 1:1 - E El El If hydrostatic testing was performed, describe what was done with the water after completion of tests: moved from 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: r Ak Date: 07/13/2007