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S\VRCB,January 2002 Page 1 . <br /> Secondary Containment Testing Report Form <br /> 771 is loan is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> ulprohriale pages o/'lhis form to report results for all components tested. The completed form, written test procedures, and <br /> prilaouts lronz tests (if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facilitv Name: ARCO #06080, CC 18022649Date of Testing: 08/25/2009 <br /> Facilitv Address: 85 E LOUISE AVE PTO N-71, LATHROP, CA, 95330 <br /> Facilitv Contact: MANGER Phone: (209) 983-9144 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY REHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> l'echnician Conducting Test: JOEY MESA <br /> Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH. I License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 01/08/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repair <br /> Tested Made p Tested <br /> Spill Box 1 REG FILL M 1-10 <br /> E 1-1 1:1 1:1 ❑ ' <br /> Spill Box 2 PLU FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 PRE FILL X ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> El D 0 El 01 E El <br /> El El 1:1 El El <br /> El E El El El El <br /> El El E El 0 El El <br /> El E] El El El El El <br /> El D El F-1 El 1:1 El El <br /> El El 0 0 El 0 El <br /> 0 <br /> I f hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WASTE DRUM ONSITE. <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: l�' Date: 08/25/2009 <br />