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SWRCI3. Januar 2002 I'aae 1 <br /> Secondary Containment Testing Report Form <br /> phis/brill is intended for use by contractors perforrnzing periodic testing of UNI'secondary containment sI stenos. I:se the <br /> appropriate pages gf this form to report results for 4111 components tested. The completed form, written test procedures, and <br /> printotNs from tests (if applicable), should be provided to the/ucilin,owner operator/br submittal to the local regulatory cr>>encr. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO #02133, CC 18022644 Date of Testin-,: 04/16/2007 <br /> FacilitN Address: 2908 BENJAMIN HOLT DR. STOCKTON, CA, 95209 <br /> Facilit,, Contact: MARKPhone: (800) 964-0180 <br /> Date Local Agency Was Notified of Testing : / / <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: CSLB Licensed Contractor SWRCI3 Licensed"I'ank Tester <br /> License Type: License Number: <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 Fait Tested <br /> Made <br /> Spill Box 1 REG FILL M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 REG FILL Fx] ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 PRE FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 0 0 El 0 0 0 El- <br /> El <br /> 0 0 0 El 0 0 0 <br /> 0 0 1:1 0 0 0 0 0 <br /> 0 0 0 0 El 0 0 0 <br /> 0 El 0 0 0 0 0 0 <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 0 0 0 0 0 0 0 0 <br /> 0I El I IF-11Ell 0 0 <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 gf my knowledge, the facts stated in this doczznzent are accurate and in full counpliance with legal requirements <br /> Technician's Signature: l lr Date: 04/16/2007 <br />