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SWRCB,January 2002 Page 1. Secondt Containment Testing ReAt 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON 201761 Date of Testing: 10/21/2010 Facility Address: 1103 S. MAIN ST. PERMIT NUMB. N-3315, MANTECA, CA, 95337 Facility Contact: MGR - MARIE Phone: (2 0 9) 825-0174 Date Local Agency Was Notified of Testing Name of Local Agency Inspector(if present during testing): none 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JARROD COOKE Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: a I License Number: 743160 Manufacturer Training Manufacturer Component(s) Date Training Expires tanknology all 07/17/2011 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair ss Component Pass Fail Tested Made Component Pass Fail Tested Made Tank Annular 2 REG ❑ ❑ ❑ UDC 7/8 ❑ Efl ❑ ❑ Tank Annular 3 REG X ❑ ❑ ❑ UDC 9/10 E ❑ El ❑ Tank Annular 1 SUP El 1 ❑ ❑ ❑ UDC 11/12 X ❑ ❑ ❑ Secondary Pipe 2 REG REGTWO El ❑ ❑ ❑ UDC 7/8 El ❑ ❑ ❑ Secondary Pipe 3 REG X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe 1 SUP SUP � ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 2 REG X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 3 REG El ❑ ❑ ❑ ❑ ❑ E ❑ Piping Sump 1 SUP E ❑ ❑ ❑ El 01 E UDC 1/2 a ❑ ❑ ❑ ❑ ❑ ❑ ELI UDC 3/4 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 5/6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: taken water dog CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the e/facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 10/21/2010