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• • <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO#2076 Date of Testing: 1/5/07 <br /> Facility Address: 800 E.Kettleman Ln.,Lodi,CA 95240 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SB989—3yr.Compliance Test <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> FAvailable <br /> BLE Maintenance,Inc. <br /> ting Test: James Moore/I.C.C.#5254517-UT <br /> ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> ,Haz.,C10 License Number: 312844 <br /> Manufacturer Training <br /> r Com onent s Date Training Expires <br /> request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Notes: <br /> Pass Fail <br /> Component: Tested Made <br /> Tank Annular - 4 X ❑ ❑ ❑ <br /> Secondary Pipe - 5 X ❑ ❑ ❑ <br /> Turbine Sump - 4 X [I L1 ❑ <br /> UDC - 4 X [10 ❑ <br /> Fill Sump - 4 X ❑ ❑ ❑ <br /> TLM Sump - 0 ❑ ❑ X ❑ <br /> Spill Bucket - 8 X [I <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> *** 6 X 55 gal. —Drums left on site. <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: <br />