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i GHTLfR-RYAN INC. GR Job#. 20-581053 SWRCB,January 2002 Page 1 of 2 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 complete 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: West Valley Chevron Date of Testing: 8/3/2012 Facility Address: 261.5 West Grantline Rd.,Tracy Facility Contact: Phone: Date Local Agency Was Notified of Testing: 7/6/2012 1IName of Local Agency Inspector(if present during testing): 2.TESTING CONTRACTOR INFORMATION - �CompanyNrn,:. - Gettler-Rya-n-lnr.:6747 Sierra Court,%-te 3,Dtiblin,-Ca?I-4_569-P-h.#-925-551-7555 — - -- Technician Conducting Test: Eldio Sanchez Credentials: CSLB Licensed Contractor License T e: C57 B C61/1)40 IIAZ A C10 License Number: 220793 Manufacturer Training Manufacturer Component(s) Date Training Ex 'res Incon Test System Operation Hydrostatic Testing 6/25/2014 Phil-Tite Spill Containment 7/29/2013 Opw Spill Containment 4/28/2013 ICC Technician UST Components 9/13/2013 3. SUMMARY OF TEST RESULTS Components Pass Fail Not Repairs Components Pass Fail Not Repai Tested Made Tested Mad, Diesel STP x 91 STP x 87 STP x If hydrostatic testing was performed,describe what was done with the water after completion of tests: 5-55 gal drums onsite CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in All compliance with legal requirements i �� Technician's Signature: � Date: 3-Aug.