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SWRCB, January 2002 Page 1. Second0y Containment Testing a 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 (if 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: 02/02/2009 Facility Address: 3725 N. TRACY BLVD TRACY, CA, 95376 Facility Contact: MANAGER Phone: (2 0 9) 835-7608 Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): MICHELLE HENRY INFORMATION2. TESTING CONTRACTOR Company Name: TANKNOLOGY, INC. Technician Conducting Test: BRYAN KEYS Component - Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: Manufacturer License Number: 07-1735 Manufacturer Training Component(s) Date Training Expires OPW PHASE 1 01/08/2010 Box 1 REG VAPOR 1000 ��00` 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: DRUMMED AND LEFT ON SITE. 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: 02/02/2009 Component - Box 1 REG VAPOR 1000 ��00` Spill Box 2 PLU FILL Spill Box 3 PRE FILL Spill Box 3 PRE VAPOR 'Spill Box 4 DIE FILL If hydrostatic testing was performed, describe what was done with the water after completion of tests: DRUMMED AND LEFT ON SITE. 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: 02/02/2009