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SWRCB,January 2002 Page 1. Seconda y Containment Testing 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CHEVRON # 96171 (N-621-1-3) Date of Testing: 01/12/2011 Facility Address: 6633 PACIFIC AVE , STOCKTON, CA, 95207 Facility Contact: MGR - SUE LYNN Phone: (2 0 9) 477-4294 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(if present during testing): garrett Backus 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JARROD COOKE Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: a License Number: 7 4 316 0 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested Made Spill Box 1 SUP FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 UNL FILL X ❑ ❑ ❑ ❑ ❑ ❑ El Spill Box 3 UNL FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F-1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ I ❑ ❑ ❑ ❑ ❑ F� ❑ ❑ ❑ ❑ ELI ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ I ❑ ❑ I ❑ ❑ ❑ ❑ 1 ❑ 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: P� Date: 01/12/2011