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SWRCB,January 2002 Page 1. <br /> Seconda*Ky Containment Testing Repdrt Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(tfapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TRACY PETRO Date of Testing: 02/25/2011 <br /> Facility Address: 3400 N. MACARTHUR DR TRACY, CA, 95376 <br /> Facility Contact: KARAM S INGH Phone: (2 0 9) 814-8581 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): THUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials: E CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: CONTRACTOR License Number. 743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> PHIL TITE PHASEI 11/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Spill Box 1 PRE FILL [fl 1:1 1:1 1:1 El El D <br /> El— <br /> Spill Box 2 REG FILL EE ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 DIE FILL El 0 1:1 1:1 El El 1:1 E <br /> Ell El Q El El El El <br /> El Ell 0 El Eli El El El <br /> Q El El El El El L <br /> E] El El El El El El <br /> Q Q El El El ll <br /> L0E-]] <br /> Ej El E <br /> El � E1 0 <br /> lEj <br /> 1 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK AS TEST WATER. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 4:: Date: 02/25/2011 <br />