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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 #201383 (N-2515) Date of Testing: 04/02/2007 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): 2. TESTING CONTRACTOR ' O Company Name: TANKNOLOGY, INC. Technician Conducting Test: CHRISTIAN ELIAS Component Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: Manufacturer License Number: Manufacturer Training Component(s) Date Training Expires Spill Box 2 2�LU FILL ' Box 3 REG FILL��0' 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 stated in this document are accurate and in full compliance with legal requirements Z4106 r Technician's Signature: 6�- C�Date: 04/02/2007 Component iSpill Box 1 SUP FILL Spill Box 2 2�LU FILL ' Box 3 REG FILL��0' 0000 ��00� s�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 stated in this document are accurate and in full compliance with legal requirements Z4106 r Technician's Signature: 6�- C�Date: 04/02/2007