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SWRCB, January 2002 <br />0 <br />Is <br />Secondary Containment Testing Report Form <br />Page 1 of 1 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility ownerfoperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON 210997 (N-4693) bate of Testing: 2/7/2013 <br />Facility Address: 1442A COLONY DR. , RIPON, CA 95366 <br />Facility Contact: PATTY Phone: 599-0149 <br />Date Local Agency Was Notified of Testing; <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials: F CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br />License Type: a License Number: 743160 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />tanknology all 5/16/2014 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box T1:SUPREME UNLEADED <br />premium fill <br />X <br />Spill Box T2:REGULAR UNLEADED <br />re ular fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: na <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 2/7/2013 <br />WO: 2309194 <br />