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SWRCB, January 2002 40 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 (rf opplicable), should be provided to the facility owner/operator Jar submittal to the local regulatory agency. 1. FACILITY INFORMATION FacilityName: CHEVRON 91452 Date of Testing: 01/04/2006 Facility Address: 334 E. MAIN ST ® HWY 99, RIPON, CA, 95366 Facility Contact: DEALER - DONNA Phone: (209) 599-2313 Date Local Agency Was Notified of Testing: / / Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. MMINER Technician Conducting Test: KELVIN CRUZ Component Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: License Number: Manufacturer Manufacturer Trainin¢ Component(s) Date Training Expires :. 0000 3. SUMMARY OF TEST RESULTS If hydrostatic testing was perfonned, 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 full compliance with legal requirements Technician's Signature: � Date: 01/04/2006 MMINER Component :. 0000 ��00 MD00 Mm00 0mm0 mm00 000 ��00 _000 ��00 If hydrostatic testing was perfonned, 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 full compliance with legal requirements Technician's Signature: � Date: 01/04/2006