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SWRCB, January 2002 0 is 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: CHEVRON #208117 Date of Testing: 04/01/2008 Facility Address: 755 S. TRACY BLVD TRACY, CA, 95376 Facility Contact: MGR - MARIA Phone: (2 0 9) 830-0370 Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. M E�=� Technician Conducting Test: SCOTT HOLMAN Component Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester 000� License Type: Manufacturer I License Number: Manufacturer Training Component(s) Date Training Expires ao�o 0000 If hydrostatic testing was performed, describe what was done with the water after completion of tests: 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: 12i -'mj Date: 04/01/2008 M E�=� F" M-Ei= Component . :.Component 000� ao�o 0000 000 0000 noon 0000■ o000 0000■ 0000 �000 o��o 000� onoo ��0000 o�oo ��000� 0000 0000 000 ■ a000 0000 If hydrostatic testing was performed, describe what was done with the water after completion of tests: 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: 12i -'mj Date: 04/01/2008