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SWRCB,January 2002 Page 1. <br /> SecondaryContainment Testing RepolfForm <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(fopplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: TRACY PETRO I Dateof Testing: 03/01/2011 <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): n/a <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: icc I License Number: 8016974 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular 1 PRE ❑ ❑ ❑ ❑ UDC 7/8 X❑ ❑ ❑ ❑ <br /> Tank Annular 2 REG ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Tank Annular 3 DIE ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 1 PRE x ❑ ❑ ❑ ❑ ❑ 1 ❑ I ❑ <br /> Secondary Pipe 2 REG ❑ ❑ ❑ ❑ Ej ❑ ❑ <br /> Secondary Pipe 3 DIE DIESEL E] ❑ ❑ ❑ El ❑ ❑ ❑ <br /> Piping Sump 1 PRE ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 2 REG E ❑ ❑ [--] ❑ El ❑ <br /> Piping Sump 3 DIE El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> put in waterdog <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, thefacts stated <br /> �i(n�this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: J(_w-- 0�^' Date: 03/01/2011 <br />