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® * <br /> SWRCB,January 2002 Page 1 of 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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if <br /> 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 CC 18022760 jDate of Testing:3/14/2018 <br /> Facility Address:3425 TRACY BLVD ,TRACY,CA 95376 <br /> Facility Contact:MANAGER(N-80-1-4) Phone:209-835-1605 <br /> Date Local Agency Was Notified of Testing:3/1/2018 <br /> Name of Local Agency Inspector(if present during testing):not present <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: W CSLB Licensed Contractor r�' SWRCB Licensed Tank Tester <br /> License Type:a License Number:743160 Room <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 4/26/2020 <br /> L- <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular#T-1 x Fill Containment for Tank:T-1 regular-I x <br /> Tank Annular#T-2 x Fill Containment for Tank:T-2 regular-1 X <br /> Tank Annular#T-3 x Fill Containment for Tank:T-3 regular-1 x <br /> Tank Annular#T-4 x Fill Containment for Tank:T-4 premium-1 x <br /> Secondary Pipe Test(Tank T-2-regular) x <br /> Secondary Pipe Test(Tank T-4-premium) x <br /> Secondary Pipe Test(Tank T-1-regular) x <br /> Siphon Pipe for T-1 to T-2 and T-3 x <br /> UDC#1/2 x <br /> UDC#3/4 x <br /> UDC#5/6 x <br /> UDC#7/8 x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water trailer <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: Date: 3/14/2018 <br /> WO:2335159 <br />