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SW(iCB,Iahuary 2002 Page 1. <br /> SecondavyContainment 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(�f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: YRC 813 Date of Testing: 04/13/2010 <br /> Facility Address: 1535 E PESCADERO AVE TRACY, CA, 95304 <br /> Facility Contact: CHRIS ROY Phone: (209) 993-7946 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Stacy and ray <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials: ❑K CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: icc License Number: 8016974 ut <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ebw spill bucket 06/25/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 WAS FILL ❑ [K] ❑ M ❑ 1:1 D <br /> Spill Box 1 WAS FILL El ❑ ❑ ❑ 0 0 0 <br /> Spill Box Others FILL ❑ Efl ❑ ❑X 1:1 0 El <br /> Spill Box Others FILL X ❑ ❑ ❑ Ej Q E <br /> Spill Box 3 ANT FILL El ❑ ❑ ❑ 0 0 D <br /> Spill Box 4 GEA FILL El ❑ ❑ ❑ 0 ❑ <br /> Spill BOX 5 MOT FILL El ❑ ❑ ❑ <br /> Spill Box 6 WAS FILL El ❑ ❑ El El El El El <br /> El El El El El <br /> El El EJ El El <br /> ❑ ❑ ❑ El ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ I ❑ ❑ I ❑ I ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> put in drum and label <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: 0 Q�+�vDate: 04/13/2010 <br />