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SWRCB, January 2002 9 Page of 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 Dat of Testing: 1/14/2009 Facility Address: 341 E. MAIN, RIPON, CA 95366 Facility Contact: ANGLE Phone: (209) 559-4544 Date Local Agency Was Notified of Testing: 1/2/2009 Name of Local Agency Inspector (ifpresent during testing): MUNI 2. TESTING CONTRACTOR INFORMATION Company Name: SST -Service Station Testing Technician Conducting Test: Heath A. McEver Credentials: u CSLB Licensed Contractor k1 SWRCB Licensed Tan' Tester License Type: Service Technician License Number: 04-16, I <.. „ , Manufacturer Training Manufacturer Component(s) Date Training Expires OPW SPILL BUCKET 06/06/2010 Component Pass Fail Not Tested Repairs Made Compone ,t Pass Fail Not Tested Repairs Made 87 FILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 FILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Il— F1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: TRANSPORTED AS TEST FLUID CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDU(. TING 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: -- Date: