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SWRCB, January 2002 Page 1. SecondAy Containment Testing Rep t 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: 02/04/2011 Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW, 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): Thuy CONTRACTOR2. TESTING OR Company Name: TANKNOLOGY, INC. Technician Conducting Test: STEVEN WILLEMS jff�fj g, MW Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester RIME License Type: icc Manufacturer License Number: 8016974 Manufacturer Training Component(s) Date Training Expires phil tite spill bucket 06/07/2012 ��, If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in buckets with lids and take with me 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: Date: 02/04/2011 jff�fj g, MW Component RIME • Box ■rte■��i ��, If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in buckets with lids and take with me 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: Date: 02/04/2011