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SWRCB,January 2002 Page 1. Seconda[r, Containment Testing Repent Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(fapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION FacilityName: YRC 813 Date of Testing: 10/06/2010 Facility Address: 1535 E PESCADERO AVE TRACY, CA, 95304 Facility Contact: KRIS/ ROY Phone: (209) 993-7946 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(if present during testing): none 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JARROD COOKE Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: a License Number: 743160 Manufacturer Trainin¢ Manufacturer Component(s) Date Training Expires tanknology all 07/17/2011 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested Made Tank Annular 4 GEA IT] ❑ ❑ ❑ ❑ ❑ ❑ El- Tank Tank Annular 6 WAS E E D D Tank Annular 5 MOT E ❑ ❑ ❑ ❑ ❑ ❑ El- Tank Tank Annular 7 WAS X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe 1 WAS X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe 2 WAS FIELD El ❑ El El E Q El Secondary Pipe 3 ANT U ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe 4 GEA ❑X D El El El El El Piping Sump 1 WAS X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 1 WAS M ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 3 ANT M ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 4 GEA ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: taken water dog CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 10/06/2010