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SWRCB,January 2002 SeCOIIt� y Containment Testing Rept Form Pagel. r 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 208118 N-4087-1-3 Date of Testing: 10/15/2010 Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA, 95212 Facility Contact: MANAGER Phone: (2 0 9) 477-3699 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: 74 316 0 Manufacturer Training Manufacturer Component(s) Date Training Expires tanknology all 07/17/2011 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested —Made Tank Annular 1 SUP ❑ ❑ ❑ El ❑ Tank Annular 2 UNL X ❑ ❑ ❑ ❑ El 0 Secondary Pipe 1 SUP SUP X ❑ ❑ ❑ ❑ El El Secondary Pipe 2 UNL REG ❑ Q ❑ El Piping Sump 1 SUP FRI ❑ ❑ El ❑ ❑ El El- Piping Sump 2 UNL E ❑ ❑ ❑ El El FI El UDC 1/2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 3/4 F71 ❑ El ❑ ❑ El ❑ El UDC 5/617-7 ❑ ❑ ❑ El F� El E UDC 7/8 Fx] ❑ ❑ ❑ El El 0 E UDC 9/10 X ❑ ❑ ❑ FI El F-1 El UDC 11/12 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 10/15/2010