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SEVRCB January 2002 Page 1. <br /> Secondary Containment Testing Report 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(fapplicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: TRACY PETRO Date of Testing: 02/26/2010 <br /> Facility Address: 3400 N. MACARTHUR DR TRACY, CA, 95376 <br /> Facility Contact: KARAM SINGH Phone: (209) 814-8581 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): STACEY RIVERA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DANIEL ROLLINS <br /> Credentials: EICSLB Licensed Contractor F-1 SWRCB Licensed Tank Tester <br /> License Type: ICC License Number: 8011610 <br /> Manufacturer Training <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 /> Spill Box 1 PRE FILL Efl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 REG FILL Efl ❑ ❑ ❑ ❑ ❑ ❑ <br /> El- <br /> Spill Box 3 DIE FILL ❑ [R] ❑ E 1:1 ❑ ❑ ❑ <br /> Spill Box 3 DIE FILL X ❑ ❑ ❑ 1:1 ❑ ❑ ❑ <br /> E � D D El <br /> El 0 Ej <br /> El <br /> El � EJ El 0 � El <br /> Q El El Q D 0 <br /> ED <br /> 0 H El E] Ej El El 11 <br /> I Ej Q Q Q � E Ej <br /> El � E D <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT ONSITE <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge, theeffacttss/ «l'�S <br /> stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �. 1`uDate: 02/26/2010 <br />