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• <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors perfarming periodic testing of UST.recondary 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 ftfapplicahle),should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCH ARCO I Date of Testing: 11/3/2014 <br /> Facility Address: 4855 S HWY 99,STOCKTON I County SAN JOA UIN <br /> Facility Contact: GILL _ Phone: 209-481-7445 <br /> ----------- -------- ------ <br /> Date Local Agency Was Notified of Testing: Thursday,October 16,2014 — <br /> Name of Local Agency Inspector(nf present during testing): NONE <br /> 2. 'TESTING CONTRACTOR INFORMATION <br /> Company Name:. B.Z.Service Station Maintenance <br /> Technician Conducting Test: TIM BURKART <br /> Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed"Tank Tester <br /> License Type: ICC _ License Number: 433159 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin 6x fires <br /> NCON TS-STS AUG 2016 <br /> 3. SUMMARY_OF TEST RESULTS <br /> Component Pass Fail tion Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 STP SUMP 89 STP SUMP ❑ <br /> 91 STP SUMP ❑ . 87 QUAD FILL SUMP <br /> 89 UAD FILL SUMP <br /> P Li <br /> 87 SECONDARY LINE ® ❑ 87 SECONDARY <br /> Y MNL_ D <br /> —Q— <br /> 89 ANNULAR 91 ANNULAR ❑ <br /> _ JV 2.5..� <br /> ❑, E1 i ❑ _. <br /> If hydrostatic testing was performed,describe what was done with ie water at er comp etron of tests: <br /> —'--- <br /> TOOK AS TEST WATER <br /> ALL DISP WILL BE TESTED ON A SECOND DAY <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 Signoture: __-,___-._. Date: 11/3/2014 <br /> Secondary Containment Test Results I of 6 <br />