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SWRCB,January 2002 Page 1. Second*y Containment Testing Relort Form This form is'intended for use by contractors perforating 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 FacilityName: USA # 03696 (CHEVRON BRAND NAME) Date of Testing: 10/11/2006 Facility Address: 2448 W KETTLEMAN LN @ LOWER SACRAMENTO RD, LODI, CA, 95242 Facility Contact: MGR - DAVE Phone: (2 0 9) 369-3124 Date Local Agency Was Notified of Testing Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JOEY MESA Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: License Number: Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested M ade Spill Box 2-UNLEAD 2-87 E ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 3-PLUS 3-89 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ El El ❑ ❑ ❑ ❑ ❑ ❑ I El- 1:111:1 ❑ ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ ❑ 1 ❑ ❑ I ❑ ❑ 1 ❑ 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: / ��`1 it"s Date: 10/11/2006