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§WRCB,January 2002 Page I of I <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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if <br /> applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:YRC 813 Date of Testing: 10/23/2013 <br /> Facility Address: 1535 E PESCADERO AVE ,TRACY,CA 95304 <br /> Facility Contact:KRIS/ROY lPhonv.209-993-7946 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): not present <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGYINC. <br /> "technician Conducting Test:Jarrod Cooke <br /> Credentials: W CSLB Licensed Contractor l— SWRCB Licensed Tank Tester <br /> License-Iype: a License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/16/2014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Com Not Repairs <br /> p Tested Made ponent Pass Fail Tested Made <br /> Tank Annula f 5 x STP Containment for Tank waste oil tank pad X <br /> .saw oil-I <br /> Tank Animism 4 x STP ContaimneM for Tank anti freeze anditeere-I x <br /> Tank Annularll 6 X STP Containment for Tank waste oil near gate X <br /> waste oil-1 <br /> Tank Annularll7 X <br /> Secondary Pipe Test(Tank motor oil-motor oil) x <br /> Secondary Pipe Test(Tank gear oil-gear oil) x <br /> Secondary Pipe Test(Tank waste oil tank pad- X <br /> waste oil <br /> Secondary Pipe Test(Tank anti freeza-antifieere) x <br /> Sewndiry Pipe Test(Tank wash solvent-wash x <br /> solvent <br /> Secondary Pipe Test(Tank waste oil near gate- Xwaste oil <br /> STP Containment for Tank motor oil motor oil- X <br /> STP Containment for Tank gear oil gear oil-I X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken/recycled water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONS63LE FOR CONDUCTING TBZS 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: 10�—� Date: 10/232013 <br /> WO:2314332 <br />