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SWRCB, lanuaq 2002Page I of <br /> JAN 1 9 2006 <br /> Secondary Containment Testing Repc t1k(IR[pI,T AEALTH <br /> This form is intended for use by enntractors performing Periodic testing of UNT secondary &f"j $ Ilse the <br /> aplxoprtate pages of thisform to report results for all crrmlwnents tested. The completed form, aria n test "frdvres nand <br /> printouts from tests(if applicable), should be provided to the facility oamer operator for submittal to the In al regulatory agemy. <br /> 1. FACILITY INFORMATION <br /> Facilit Name: Tracy Petro, Inc Date of Testing: 1-13-06 <br /> Facilip'Address: 340(1 North MacArthur Drive; Trace, CA 93376 <br /> Facft Contact: Karam Plhp= 209-834-1220 <br /> Dam La al Agency Was Notified of Testing: 1.6-06 <br /> Name of Local Agee Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompE) Name: Dia!}'sis North <br /> Technician Conducting Test: Greg Hartman <br /> Credentials: f-I CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: License Number: 03-I(A) <br /> Manufacturer Training <br /> Manufacturer Components) Date Taining Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pas Fail ot Repairs T"ted Companeat Piss Fail Not Repairs <br /> Ta ted Made <br /> Spin Fill Box# 1 —91 }( ❑ ❑ [] <br /> ❑ ❑ ❑ <br /> Spill Fill Box#2—87 X ❑ [] ❑ ❑ ❑ ❑ <br /> Spill Fill Box#3 —Diel X ❑ 0 0 0 0 ❑ <br /> G ❑ U ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 i ❑ 0 ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> 0 ❑ 0 11 ❑ ❑ ❑ <br /> If h}drostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> ro the best of my hnmde4e, d <br /> thefacis srateinn 1kis dmwment air awmrWe and in fell conyrlignc a wiM Irgal <br /> regwirorsrrsts <br /> Technician's Signature: A4-,_ Ad--7� Date: 1 - 15 -06 <br />