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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. I= 2F."Tel 10 v Ira 113 03 9,7011y"I Facility Name: CHEVRON #201383 (N-2515) 77FTate of Testing: 04/07/2008 Facility Address: 1960 W. 11TH STREET TRACY, CA, 95376 Facility Contact: MGR - HELEN Phone: (2 0 9) 836-3181 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): CONTRACTOR2. TESTING INFORMATION Company Name: TANKNOLOGY , INC. Technician Conducting Test: DANIEL ORTIZ Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: Manufacturer I License Number: Manufacturer Training Component(s) Date Training Expires Box 2 PLU FILL000' 1 ��00 Spill Box 3 REG FILL000 3. SUMMARY OF TEST RESULTS 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 statedinthis document are accurate and in full compliance with legal requirements Technician's Signature: —D—o / Date: 04/07/2008 Spill Box 1 SUP FILL Box 2 PLU FILL000' 1 ��00 Spill Box 3 REG FILL000 N N00 0000: ��00 0000 ��00 0000' ��00 000 ��00 ■a000 �■■■��■0000 ■■�0000� o000 a000 0000 �0000� 0000 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 statedinthis document are accurate and in full compliance with legal requirements Technician's Signature: —D—o / Date: 04/07/2008