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SWRCB,January 2002 GR Job# 18200927.1 Page 1 of 2 <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Arco 02093 Date of Testing:0 3 2 7 2 018 <br /> Facility Address:3425 N. Tracy Blvd <br /> Facility Contact:Daryl Lee Phone:415 . 902 .5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompanyRan Inc. <br /> Technician Conducting Test:David Rouse RNVIR <br /> ONNIENTAt <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number:2 2 0 7 9 3 <br /> Manufacturer Trainine <br /> Manufacturer Com onen s Date Trainin f-xpires <br /> Incon TS-ST5 09/2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Slave STP 0 ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> 87 Master STP 0 ❑ ❑ ❑ <br /> 87 Siphon STP 0 ❑ ❑ 0 ® 0 0 ❑ <br /> 91 STP 0 ❑ ❑ ❑ 0 ® I ❑ ❑ <br /> D D 0 ❑ ❑ ❑ 0 ❑ <br /> a a ❑ ❑ o ❑ ❑ ❑ <br /> D a ❑ a 0 a a D <br /> ❑ a ❑ ❑ ❑ a ❑ ❑ <br /> D 1 D ❑ ❑ 0 a a D <br /> ❑ a ❑ a a a a <br /> D D a ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ D a D <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 meat are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 03/27/20108 <br />