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0 6 <br /> 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 #02133, CC 18022644 Date of Testing: 03/26/2008 <br /> Facility Address: 2908 BENJAMIN HOLT DR. , STOCKTON, CA, 95209 <br /> Facility Contact: MARK Phone: (8 0 0) 964-0180 <br /> Date Local Agency Was Notified of Testing: 03/18/2008 <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DENNIS RUE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC License Number: 5246067-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKETS 01/08/2010 <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 REG FILL P] ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> Spill Box 2 REG FILL ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> Spill Box 3 PRE FILL X ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> 0 0 <br /> 0 0 0 0 0 0 El <br /> ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> El 0 El 0 0 El- <br /> El <br /> 0 0 0 0 0 <br /> El- <br /> 0 0 0 El El El 0 0 <br /> 0 0 0 El 0 0 <br /> El E 0 0 El <br /> TEIT E] 1:1 0 0101 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PUT IN ON SITE DRUM. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts statedinthis document are accurate and in full compliance with legal requirements <br /> Technician's Signature: - ®t A Date: 03/26/2008 <br />