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SWRCB,January 2002 19 q 5l9 p —ROE Page_of_ Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use rhe 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: TEXACO Date of Testing: 6/30/09 Facility Address: 1405 CALIFORNIA,ESCALON,CA 95320 Facility Contact: CHOCO Phone: 209-838-7674 Date Local Agency Was Notified of Testing: 6-23-09 Name of Local Agency Inspector(f present during testiny�: 2. TESTING CONTRACTOR INFORMATION Company Name: SST-Service Station Testing Technician Conducting Test: Heath A.McEver Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: Tank Tester,Technicain License Number: 04-1677 Manufacturer Training Manufacturer Com onent(s) Date Training Expires INCON TS STS 10-13-10 3. SUMMARY OF TEST RESULTS Not RepairsNot Repairs Component Pass Fail Tested Made Component Pass Fad Tested Made 87191/DSLANNULAR X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 SEC LINE X ❑ ❑ ❑ Cl 0 ❑ ❑ 91 SEC LINE X ❑ ❑ 0 ❑ G ❑ DSL SEC LINE X F ❑ ❑ ❑ ❑ ❑ ❑ 87 STP SUMP X ❑ ❑ ❑ 0 ❑ ❑ 0 91 STP SUMP X 0 ❑ ❑ 0 ❑ 0 0 DSL STP SUMP X 0 ❑ 0 0 ❑ ❑ 0 DISP 1-2 X 0 0 ❑ ❑ ❑ ❑ C DISP 3-4 X ❑ ❑ 0 ❑ 0 ❑ 0 -- 0 0 ❑ ❑ E ❑ ❑ 0 ❑ 0 ❑ ❑ ❑ 0 ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Transported as test fluid CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated't this document are accurate and in full compliance with legal requirements Technician's Signature: Date.