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SWRCB, January 2002 v I ~ Page of <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 />r <br />r <br />r <br />V <br />Facility Name: YELLOW ROADWAY CORPORATION -TRACY Date of Testing: 12/02/04 <br />Facility Address: 1535 E. PESCADERO AVE. TRACY, CA. 93504 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing: 11/30/04 <br />Name of Local Agency Inspector (ifpresent during testing): DENNIS CATANYAG, R.E.H.S. <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: PROFESSIONAL SERVICE INDUSTRIES <br />Technician Conducting Test: <br />STEVEN A. SILLS <br />Credentials: X CSLB Licensed Contractor S WRCB Licensed Tank Tester <br />License Type: A, C57 <br />I License Number: 716703 <br />Manufacturer <br />Manufacturer Traint_ny <br />Component(s) Date Training Expires <br />INCON <br />INCON SUMP TESTING 7-1-2006 <br />MONITORING SYSTEM <br />3. SUMMARY OF TEST RESULTS <br />Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />I JUNK OIL PIPING SUMP X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER TRANSFERRED TO AN ON-SITE OIL/WATER SEPERATOR FOR <br />PROCESSING AND DISPOSAL. <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: r Date: /-?7 O y <br />