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SWRCB,January2002 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO #2133, CC 18022644 1 DateofTesting: 04/20/2006 <br /> Facility Address: 2908 BENJAMIN HOLT DR. STOCKTON, CA, 95209 <br /> Facility Contact: MARK Phone: (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: —❑ <br /> DAVID MATHIE E] SWRCB Licensed Tank Tester <br /> Credentials: El CSLB Licensed Contractor <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 Repairs <br /> Component Pass Fain Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 87 S x F-1 I El El ❑ El El E]_ <br /> Spill Box 2 87 M E!ij r___1 <br /> ❑ 0 El 0 0 El 1:1 <br /> Spill Box 91 r___1 E <br /> E] 0 ❑ <br /> ❑ F-1 F-1 El 0 El I ❑ I El <br /> ❑r_1 I F1 0 F] El El r_1 I El <br /> IF] 10 El Ell 0 El 0 <br /> ❑ F-1 10 1:1 Ell El r-1 0 <br /> El I El I El El El 0 F-1 <br /> 1_1 I r-1 I ❑ I El El El ❑ 0 <br /> El 0 0. F-1 El <br /> El El 1:1 El DIED 1:1 E] <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 0;(404a. Date: 04/20/2006 <br />