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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: 09/14/2009 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): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Pass Fail Technician Conducting Test: STEVEN WILLEMS Component Pass Credentials: Not Tested CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester FRI El License Type: I License Number: El D Manufacturer Manufacturer Trainine Component(s) Date Training Expires ❑ ❑ ❑ 1:1 ❑ D E Spill Sox 3 DIE FILL � ❑ ❑ ❑ El El 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Mad Spill Box 1 UNL FILL ❑ FRI El El LJ El D E Spill Box 2 PRE FILL X ❑ ❑ ❑ 1:1 ❑ D E Spill Sox 3 DIE FILL � ❑ ❑ ❑ El El El El - Spill Box 1 UNL FILL ❑ 17-71 ❑ ❑ El El D El Ll F1 El El El El EI - El El F] El El El El El El E El El El El El El El El El D El El El El El El El D El D El El El El El El El E El El El El El El EE 1:1 I Di El Ll D 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, thefacts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 09/14/2009