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*REC' SWRCB, January 2002 age a4u Secondary Containment Testing Report Form JUL 2.$ 2011 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, written2W111:�10 printoutsfrom tests (if applicable), should be provided to the facility owner/operator for submittal to thepcy 1 _ FACILITY INFORMATION Facility Name: SMK Collier Road Chevron Date of Testing: June 9, 2011 Facility Address: 25651 North Highway 99, Acampo, Ca. 95220 Facility Contact: Tony Singh I Phone: (209) 333-1740 Date Local Agency Was Notified of Testing: 6/2/11 by Afford -A -Test Name of Local Agency Inspector (if present during testing): TF.CTYNG CONTRACTOR INFORMATION 3. SUMMARY OF TEST RENULTN Component Pass Fail Not Repairs Tested Made Component Pass Fail Not Tested Repairs Made Annular Tank #1 X ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ Annular Tank #2 X ❑ ❑ ❑ Dispenser Sump #9&10 X ❑ ❑ ❑ Annular Tank #3 X ❑ ❑ ❑ Dispenser Sump #11&12 X ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ Fill Riser Sump #1 X ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ Fill Riser Sump #2 X ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ Fill Riser Sump #3 X ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ I❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. 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: June 9, 2011