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SWRCB, January 2002 <br />Page 1 of 1 <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: CHEVRON 208118 N-4087-1-3 jDate of Testing: 2/22/2013 <br />Facility Address: 3355 E. HAMMER LANE @ HOLMAN RD, STOCKTON, CA 95212 <br />Facility Contact: MANAGER Phone: 477-3699 <br />Date Local Agency Was Notified of Testing:2/11/2013 <br />Name of Local Agency Inspector (if present during testing): garrett <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Steven Willems <br />Credentials: W, CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: a License Number: 743160 MMEEM <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />phil tite spill bucket 10/16/2014 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box T1 supreme fill <br />X <br />Spill Box T2 regular fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thefa11cts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: W JQQ,. Date: 2/22/2013 <br />WO: 2309196 <br />