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10/22/2008 12:01 9163712450 BZ MANITANENCE PAGE 02/10 <br /> • a <br /> S WRCB,Jamwry 2002 Page_of y <br /> Secondary Containment Testing .Report Forma <br /> This form is intended for use by contractor's performingperiodic testing of 115T secondary containment systems, Use the <br /> appropriate pages of this fort to report restdls forall components tested. The completed far,written test procedures,and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submival to the local regulatory agen. , <br /> 1. FACILITY INFORMATION <br /> Facility Name: Arch Arco AMRM I Date of Testing: 4/10/08 <br /> Facility Addrem: 4855 Hwy 99 Stockton,CA 95215 <br /> Facility Contact: Gil! I Phone: 209-948-2438 <br /> Date Local Agency Was Notified of Testing! 3/17/08 <br /> Name of Local Agency Inspector(if present dwing testing: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: B.Z Service Station Maintenance <br /> Technician Conducting Test: James Norby <br /> Credentials: X CS.LB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type; ICC 5246092-UT License Number:433159 <br /> Manufacturer Trai <br /> M Hint , <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> cmepnnent Pass Pail Not Repairs Component pass Buil Not Repairs <br /> Toted Made Toted Mndc <br /> 87 STP Sump X ❑ 0 0 87 Annular X ❑ ❑ ❑ <br /> 89 STP Sump X ❑ ❑ 0 89 Annular X 0 L ❑ <br /> 91. STP Sump X 0 ❑ ❑ 91 Annular X p 0 U <br /> ❑ ❑ ❑ 0 UDC# 1 & 2 X Li ❑ ❑ <br /> 87 Fill Sump X 1 ❑ 0 0 UDC#3 & 4 X 0 Ll ❑ <br /> 89 Fill Sump X ❑ 0 ❑ UDC# 5 W6 X 0 C] ❑ <br /> 91 Fill Sump X ❑ ❑ 0 UAC# 7 & 8 X ❑ ❑ 0 <br /> ❑ L7 ❑ ❑ UDC#9 & 10 2i ❑ ❑ ❑ <br /> _87 Secondary Piping X IJ ❑ ❑ UDC# 11 & 1.2 X 0 ❑ ❑ <br /> 89 Secondary Piping X ❑ ❑ ❑ UDC# .1.3& 24 X ❑ ❑ ❑ <br /> 91 Secondary Piping X 0 ❑ ❑ UDC# 15& 16 X I'] ❑ ❑ <br /> C 1 ❑ ❑ ❑ UDC # 17& 1.8 X [] ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of test%: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest nfmr knowledge,the ed-l0 this document are accurate red in fu 11 compliance with legal requirements <br /> Technician's Sigattire' _1�— _ Date: 4/1.0/08 <br />