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SWRCB, Ianuary 2002 Page 1. Secondt Containment Testing Rep rt 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: SHELL # 136186 Date of Testing: 12/22/2009 Facility Address: 3725 N. TRACY BLVD , TRACY, CA, 95376 Facility Contact: MANAGER Phone: (2 0 9) 8 35-7 608 Date Local Agency Was Notified of Testing : 12 / 16 / 2 0 0 9 Name of Local Agency Inspector (if present during testing): MICHELLE HENRY 2. TESTING CONTRACTOR Company Name: TANKNOLOGY, INC. Pass Technician Conducting Test: CHARLES FERRUCCI Repairs Made Component Credentials: a CSLB Licensed Contractor Repair Made SWRCB Licensed Tank Tester a License Type: icc Manufacturer I License Number: 5323096 -UT Manufacturer Training Component(s) Date Training Expires OPW SPILL BUCKET 11/04/2009 ❑ ❑ Spill Box 1 REG VAPOR a ❑ ❑ ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 1 REG FILL a ❑ ❑ ❑ ❑ El ❑ ❑ Spill Box 1 REG VAPOR a ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU VAPOR X ❑ ❑ ❑ a ❑ ❑ ❑ Spill Box 3 PRE FILL X ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 3 PRE VAPOR x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 4 DIE FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑❑❑ ❑❑❑❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: LEFT WATER ON SITE IN DRUM LABELED 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: �Ae,,t fDate: 12/22/2009 �yitli6a�'a