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Page 1 of 8 Corrected Summary Pat -Secondary Containment Aelting 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 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. Facility Name: CHEVRON #208118 Date of Testing: 8/15/2012 Facility Address: 3355 HAMMER LANE, STOCKTON, CA 95212 Facility Contact: Phone: Date Local Agency Was Notified of Testing : 8/7/2012 Name of Local Agency Inspector (zfpresent during testing): Name: Technician Conducting Test: Nick Harvey ICC #5115738 Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: A, HAZ, C21, C10, B, C61, D40 License Number: 300345 Manufacturer Training Manufacturer Components) Date Training Expires Furnished on Component : /��■ ■0� 87 Vapor.8�/ X00■ 87 Prod Secondary�1�00■ ��0■ 0 • .. Secondary Line91 /100 �■ �■ 00 STP Sump, �1 W00 MMM MM /NM■ 00 0 o 0all 0' � t C // 00■ �� ■00■ ITMOR I I /IMOD 0 01 0 R ►��0■ 0 �■ �■ 00■ 87 Fill Bucket C■ // 0 ■0 ��00 91 Fill BucketC■ // 00 �� ■00■ If hydrostatic testing was performed, describe what was done with the water after completion of tests: One (1) 55-jzallon drum was left on site 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: �`... ` = I �`-� Date: 8/15/2012