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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CRLLC#2705446 1 Date of Testing: 10/14/2010 <br /> Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br /> Facility Contact: ARMEN MKRTYTCH/AN Phone: (925)884-0800 <br /> Date Local Agency Was Notified of Testing : 10/1/10 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORP. <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: A (CSLB Lie.) License Number: 803705(CSLB Lie) -- 06-1672(SWRCB Lie) <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC CA UST SERVICE TECHNICIAN#5254736-UT JAN 22,2011 <br /> SCWRCB TANK TESTER LICENSE#06-1672 JUN 30, 2012 <br /> FRANKLIN FUELING /NCON SUMP TESTER#957353761 MAR 2, 2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 PRODUCT SECONDARY ❑ ® ❑ ❑ UDC#5-6 ® ❑ ❑ ❑ <br /> 87 TANK VENT LINE ❑ ❑ ® ❑ UDC#7-8 ❑ ® ❑ ❑ <br /> 87 STP SUMP ® ❑ ❑ ❑ WASTE OIL PRODUCT ❑ ® ❑ ❑ <br /> SECONDARY <br /> 91 PRODUCT SECONDARY ® ❑ ❑ ❑ WASTE OIL TANK VENT LINE ® ❑ ❑ ❑ <br /> 91 TANK VENT LINE ❑ ❑ ® ❑ WASTE OIL STP SUMP ® ❑ ❑ ❑ <br /> ® 91 STP SUMP ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> DIESEL PRODUCT SECONDARY ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DIESEL TANK VENT LINE ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> ® DIESEL STP SUMP ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> VAPOR RECOVERY LINE ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> UDC#1-2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#3-4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> —11 <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: �—L U� Date: 10/14/2010 <br />