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SWRCB,January 2002 Page 1. <br /> Secondaf'y Containment Testing Repert 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 testprocedures, and <br /> pnntoutsfrom tests(if applicable),should beprovided to thefaciliry owner/operatorforsubmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: YRC 813 Dateof Testing: 03/24/2011 <br /> Facility Address: 1535 E PESCADERO AVE TRACY, CA, 95304 <br /> Facility Contact: KRIS/ ROY Phone: (209) 993-7946 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): TUEY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: CHARLES FERRUCCI <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: I License Number: 5323096-VT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Spill Box 1 WAS FILL El 0 El 1:1 1:1 1:10 <br /> Spill Box 3 ANT FILL EK] El El El El El Ej- <br /> EL <br /> Spill Box 4 GEA FILL 0 <br /> El <br /> Spill Box 5 MOT FILL El1:1 ❑ 1fl D ❑ ❑ <br /> El E D El El LI <br /> Ej Ej El L1 El El El <br /> El I El El [E] El El El <br /> El I El 1:1 E El El <br /> ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El E El <br /> Ej- <br /> El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:�y/ r ,��� Date: 03/24/2011 <br />