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E <br />S\\ RC13. lanuan 2002 <br />E <br />Secondary Containment Testing Report Form <br />phis JornI is iIle ndecI for Ilse by contracnrr.s performing periodic• Testing 0J ( ST secondart, containment sI stems. I 'W the <br />appropriate pages of this form Io report results for all components tested 77re completed form. it rinen test procedures, and <br />printouts Iron jests lil applicable/, .should he provided to the fcrcilitl owner operator for submittal to the local rcgulcrtol r (I- /Icl , <br />FACILITY INFORMATION <br />Facilith Name: ARCO # 02093 CC18022760 <br />Dateo1-l'estin,-,: 01/10/2007 <br />Facility Address: 3425 TRACY BLVD , TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />phone: (209) 835-1605 <br />Date Local Agency Was Notified ofTesting <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conductine Test: DENNIS RUE <br />Component <br />Credentials: <br />❑ <br />CSLB Licensed Contractor <br />SWRCI3 Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />,SpillComponent <br />:. <br />0000 <br />000� <br />Spill0000 <br />3. SUMMARY OF TEST RESULTS <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 <br />, document are accurate and in fidl compliance with legal requirements <br />Technician's Signature: _4 ,9 Date:_ 01/10/2007 <br />Component <br />,SpillComponent <br />:. <br />0000 <br />000� <br />Spill0000 <br />0000 <br />Spill Box 4 REG FILL0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000.: <br />0000 <br />0000 <br />0000: <br />0000 <br />0000.. <br />0000 <br />0000 <br />0000.: <br />0000 <br />0000 <br />0000 <br />0000. <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 <br />, document are accurate and in fidl compliance with legal requirements <br />Technician's Signature: _4 ,9 Date:_ 01/10/2007 <br />