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SWRCB, January 2002 • Page 1 • • Secon�r Containment Testing Report Form Y g P 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 FacilityName: CHEVRON 307709 Date of Testing: 09/18/2009 Facility Address: 10858 TRINITY PKWY STOCKTON, CA, 95210 Facility Contact: MANAGER Phone: (2 0 9) 952-2213 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): GARRETT 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Pass Technician Conducting Test: BRYAN KEYS Repairs Made Credentials: EI CSLB Licensed Contractor SWRCB Licensed Tank Tester Repair Made License Type: I License Number: 07-1735 Manufacturer Manufacturer Training Component(s) Date Training Expires PHILTITE PHASE 1 12/19/2009 ❑ El El E 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 1 UNL FILL ❑ ❑ ❑ ❑ ❑ ❑ El El E El El E E E El El E 1:1 1:1 F-1 El D El El D D 1:1 El El El El - El El El El 11:11 1:1 El D E E El El El El E El El El D F1 El D El El El 1:1 El El El El 11 F1 El D El El If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECIINICIAN 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: 09/18/2009