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SWRCB,January 2002 • <br /> Page 1 . <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors pei forming periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completes%form, written test procedures, and <br /> printouts from tests•(if applicable), should be provided to the•facility owner/operator f r submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO 02076, CC 18022641 DateofTesting: 05/02/2007 <br /> Facility Address: 800 KETTLEMAN LN PTO N-85, LODI, CA, 95240 <br /> Facility Contact: MANGER Phone: (209) 334-3678 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DENNIS RUE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <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 SUP FILL X ❑ ❑ ❑ ❑. ❑ ❑ ❑ <br /> Spill Box 2 REG FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 REG FILL x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 4 REG FILL x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El <br /> El El El El El <br /> El- <br /> El El El El <br /> El F-1 El E] El El <br /> El El 1 F1 <br /> El 0 <br /> El I F E] E] E] <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: Date: 05/02/2007 <br />