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SWRCB,January 2002 Page 1. <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 /> Facility Name: ARCO #06080, CC 18022649 DateofTesting: 09/27/2007 <br /> Facility Address: 85 E LOUISE AVE PTO N-71, LATHROP, CA, 95330 <br /> Facility Contact: MANGER I Phone: (204) 983-9144 <br /> Date Local Agency Was Notified of Testing: 08/30/2007 <br /> Name of Local Agency Inspector(if present during testing): TOUR YANY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH. License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 12/18/2007 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested M <br /> ade <br /> Spill Box 1 REG FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PLU FILL El ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> Spill <br /> Spill Box 3 PRE FILL 1fl 0 0 ❑ ❑ ❑ ❑ ❑ <br /> 0 0 0 0 0 0 0 El- <br /> El <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 ❑ <br /> 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 El- <br /> El <br /> 0 0 0 0 E] 1:1 . ❑ 0 <br /> 0 0 0 0 0 ❑ 0El- <br /> El 0 0 ❑ ❑ 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WASTE DRUM ON SITE. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, thef�"gacctss stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:^_" ly Date: 09/27/2007 <br />