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s t SWRCB,January 2002 Page 1. Secondary 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: SHELL CC # 136187 1 Date of Testing: 05/28/2010 Facility Address: 2375 WEST GRANT LINE ROAD N-1094-1-5, TRACY, CA, 95376 Facility Contact: MANAGER I Phone: (2 0 9) 836-8908 Date Local Agency Was Notified of Testing : 05/12/2010 Name of Local Agency Inspector(if present during testing): STACY 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: KELVIN CRUZ Credentials: EICSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: CONTRACTOR License Number: 743160 Manufacturer Training Manufacturer Component(s) Date Training Expires PHIL TITE PHASEI 11/18/2009 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested Made Spill Box 1 REG FILLIIA-11 ❑ ❑ ❑ ❑ ❑ 1:1 1:1 Spill Box 1 REG VAPOR 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 2 PLU VAPOR x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 3 PRE FILL a ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 3 PRE VAPOR 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 4 DIE FILL x ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 17 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ell ❑ ❑ Eli Eli ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: PLACED IN DRUMS. 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:_ Get Date: 05/28/2010