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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 Facility Name: CHEVRON #9 9 8 4 0 Date of Testing: 02/11/2 010 Facility Address: 4344 E WATERLOO RD @ 99, STOCKTON, CA, 95215 Facility Contact: MANAGER Phone: (2 0 9) 93 1-2186 Date Local Agency Was Notified of Testing Name of Local Agency Inspector(if present during testing): TRAN 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: BRIAN MCPHEELY Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: I CC License Number: 8010965-UT Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fait Tested Made Spill Box 1 SUP FILL ❑ ❑ ❑ ❑ ❑ EJ El Spill Box 3 REG FILL a F-11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F-1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ F-1 ❑ El -1 El El F-1❑ ❑ ❑ ❑ ❑ ❑ a ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: WATER LEFT ON SITE IN EXISTING DRUM 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: 23 Date: 02/11/2010