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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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />TTi.CT NO 1 - FAC T11TV INFORMATION <br />Page 1 of 1 <br />Facility Name: ARCO 42093 — Test No. 1 Date of Testing: 5/1/06 <br />Facility Address: 3425 Tracy Blvd., Tracy, CA 95376 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance <br />Technician Conducting Test: James Moore <br />Credentials: ff1CSL13 Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 License Number: 312844 <br />Manufacturer <br />Manufacturer Training <br />SUMMARYAF TEST RESULTS <br />Date <br />Component <br />Pass <br />Fail No <br />Te ed <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />• <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Space—All grades <br />El <br />❑ 0 <br />❑ <br />Fill Sum — 87#3 <br />© <br />❑ <br />❑ <br />❑ <br />Secondary Piping — 87-1 <br />M <br />❑ <br />❑ <br />Fill Sum — 91 <br />0 <br />❑ <br />0 <br />❑ <br />Secondary Piping — 87-2A <br />❑ <br />❑ <br />Fill & Vapor Buckets -87#1 <br />0 <br />❑ <br />❑ <br />❑ <br />Secondary Piping — 87-2B <br />El <br />❑ <br />❑ <br />Fill Bucket -87#2 <br />❑ <br />o <br />❑ <br />❑ <br />Secondary Piping — 91 <br />El <br />❑ ❑ <br />❑ <br />Vapor Bucket -87#2 <br />0 <br />❑ <br />❑ <br />❑ <br />Sec. Piping— Syphon Line <br />o <br />❑ ❑ <br />❑ <br />Fill & Vapor Buckets -87#3 <br />0 <br />❑ <br />❑ <br />❑ <br />STP Sum — 87#1 <br />© <br />❑ ❑ <br />❑ <br />Fill Bucket - 91 <br />El <br />❑ <br />❑ <br />10 <br />STP Sum — 87#2 <br />0 <br />❑ ❑ <br />❑ <br />Vapor Bucket - 91 <br />❑ <br />o <br />❑ <br />❑ <br />STP Sum — 87#3 <br />0 <br />❑ ❑ <br />❑ <br />Dispenser #1/2 <br />0 <br />❑ <br />❑ <br />❑ <br />STP Sum - 91 <br />© <br />❑ ❑ <br />❑ <br />Dis enser #3/4 <br />El <br />❑ <br />❑ <br />❑ <br />Fill Sum — 87#1 <br />© <br />❑ ❑ <br />❑ <br />Dispenser #5/6 <br />© <br />❑ <br />❑ <br />❑ <br />Fill Sum — 87#2 <br />© <br />❑ ❑ <br />❑ <br />Dispenser #7/8 <br />® 10 <br />10 <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 fact stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: <br />Date: S' %Z <br />11 <br />