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SWRCB, January 2002 Page 1. Secondary Containment Testing Report 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 307709 Date of Testing: 04/29/2011 Facility Address: 10858 TRINITY PKWY , STOCKTON, CA, 95210 Facility Contact: MANAGER (N-7462-1-10) Phone: (209) 952 -22 13 Date Local Agency Was Notified of Testing : / / Name of Local Agency Inspector (if present during testing): GARRET BACKUS 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY , INC. Technician Conducting Test: TIMOTHY ELEBECK Repairs Made Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: ICC I License Number: 8001435 Manufacturer Manufacturer Training Component(s) Date Training Expires PHIL TITE SPILL BUCKETS 08/17/2011 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in./ull compliance with legal requirements Technician's Signature: A -U—� Date: 04/29/2011 Repairs Made 000 ��00. 000 ��00. 000 ��00 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in./ull compliance with legal requirements Technician's Signature: A -U—� Date: 04/29/2011