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SWRCB,January 2002 Page 1. <br /> Second0y Containment Testing ReAt Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 201761 Date of Testing: 10/30/2007 <br /> Facility Address: 1103 S. MAIN ST. , MANTECA, CA, 95337 <br /> Facility Contact: MGR - MARIE Phone: (2 0 9) 825-0174 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: GREGORY MCHALE <br /> Credentials: El CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> TANKNOLOGY ALL 10/03/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular 1 REG Efl ❑ 0 ❑ 1:1 ❑ E <br /> Tank Annular 2 PLU X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Tank Annular 3 SUP Fx1 El ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 FRI ❑ ❑ D El 0 El E <br /> UDC 3/4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ❑ ❑ 1:1 E ❑ <br /> UDC 7/8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ❑ ❑ ❑ <br /> UDC 11/12 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 1 0 ❑ <br /> 1 1:1 El <br /> L 1:1 . Ell El I El F] El 1:1 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TAKEN — N" OA4.,C_ yn42D <br /> mN <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ilir�.r v�� � Date: 10/30/2007 <br />