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SWRCB, January 2002 is Page of 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: VALERO I I Dat,- of Testing: 12/16/2008 Facility Address: 1605 S. EL DORADO ' ` Facility Contact: ANGLE [ hone: (209) 939-1906 Date Local Agency Was Notified of Testing: 12/02/2008 Name of Local Agency Inspector (ifpresent during to"�`IEN I :1 ET a �. IjL 2. TESTING CONTRACTOR INFORMATION Company Name: SST -Service Station Testing Technician Conducting Test: Heath A. McEver Credentials: ❑ CSLB Licensed Contractor lel SWRCB Licensed Tan Tester License Type: Tank Tester, Technicain License Number: 04-1671 ,. 17,97771 =11 I Manufacturer Training Manufacturer Component(s) Date Training Expires INCON TS STS TESTER Component Pass Fail Not Tested Repairs Made Compone.at Pass Fail Not Tested Repairs Made 87/91 ANNULAR SPACE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 SECONDARY LINE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 SECONDARY LINE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 STP SUMP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 STP SUMP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISPENSER 1-2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISPENSER 3-4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISPENSER 5-6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El 11tE]] 11 ElElElEl ❑❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: PLACED IN DRUM ON SITE CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts state this document are accurate and in full compliance with legal requirements Technician's Signature: - Date: A4;