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SWRCB,January 2002 9 0 Page 1. <br /> Secondary Containment Testing Report <br /> This form is intendedfor use by contractors performingperiodic testing of USTsecondary 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: ARCO # 2093 CC18022760 DateofTesting: 01/11/2006 <br /> Facility Address: 3425 TRACY BLVD TRACY, CA, 95376 <br /> Facility Contact: MANAGER Phone: (2 0 9) 835-1605 <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 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Traininy_ <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TESTRESULTS <br /> Not Repairs Not Repair. <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 ❑X ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> Spill <br /> Spill Box 2 ❑X ElEl El ❑ ❑ El ❑ <br /> Spill Box 3 El ❑ ❑ El ❑ ❑ ❑ ❑ <br /> Spill Box 4 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ Ell ❑ ❑ ❑ <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 infill compliance with legal requirements <br /> Technician's Signature: l r/"' Date: 01/11/2006 <br />