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SWRCB, January 2002 Page 1. Second#y Containment Testing ReAt Form This form is intendedfor use by contractors performingperiodic testing of USTsecondary 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 (ifopplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON 91452 (N-618) I DateofTesting: 01/12/2007 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: TANMOLOGY, INC. Technician Conducting Test: TREVOR HANSEN Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: License Number: ��00 Manufacturer Manufacturer Training Component(s) Date Training Expires Spill Box PLUS 1 0mm0 mm00 Spill Box UNLEADED I mm=0 3. SUMMARY OF TEST RESULTS 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, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 01/12/2007 Spill Box SUPREME i 000 ��00 Spill Box PLUS 1 0mm0 mm00 Spill Box UNLEADED I mm=0 Mm00 mmm0 mm00 000 ��00 000 ��00 0000 ��00 0000 ��00 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, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 01/12/2007