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/ SWRCB,January 2002 Page 1 of i <br /> Secondary Containment Testing Report Form <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:WEST VALLEY CHEVRON jDate of Testing: 3/27/2012 <br /> Facility Address:2615 W.GRANT LINE RD ,TRACY,CA 95304 <br /> Facility Contact:LINDA Phone:836-3464 <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: Steven Willems <br /> Credentials: rv-1 CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type: tanknology License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology secondary containment 10/2/2012 <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs <br /> Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular# 1 X <br /> Tank Annular#2 x <br /> Tank Annular#3 X <br /> Piping Run#Tank 1 Line 1 X <br /> Piping Run#Tank 2 Line 1 X <br /> Piping Run#Tank 3 Line 1 X <br /> C#1/2 X <br /> UDC#3/4 X <br /> C#5/6 X <br /> C#7/8 X <br /> UDC#9/10 X <br /> UDC#11/12 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests:vent sump was tested and <br /> passed.water was put back in waterdog and taken with me. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the1 fa1cts stated in this document are accurate and in full compliance with legal requirements <br /> w <br /> Technician's Signature: ' Date: 3/27/2012 <br />