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• <br />AiltechPetr- <br />Compliance' <br />without Compromise <br />P.O. Box 4208 <br />Sonora CA 95370 <br />Ca: 623541 A-Haz <br />Phone: 209-532-7320 <br />Fax: 209-533-2650 <br />mail@alltechpetro.com <br />www.alitechpetro.com <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 pages of this <br />form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be <br />provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Hammer 1-5 Arco I Date of 5/16/12 <br />Facility Address: 3201 W. Hammer Lane Stockton CA <br />Facility Contact: Wes Parkinson Phone: (209) 474-9125 <br />Date Local Agency Was Notified of Testing : 5/10/12 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Alltech Petro Inc. <br />Technician Conducting Test: Isaac Anderson <br />Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br />License Type: A-Haz License Number: 623541 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Sump Tester 4-13-13 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Tested <br />Not <br />Repairs <br />Made <br />87 Master Turbine Sump <br />® <br />❑ <br />❑ <br />❑ <br />Vapor Transition Sump <br />® <br />❑ <br />❑ <br />❑ <br />87 Syphon Piping Sump <br />® <br />❑ <br />❑ <br />❑ <br />Piping Transition Sump <br />® <br />❑ <br />❑ <br />❑ <br />91 Turbine Sump <br />® <br />❑ <br />1 ❑ I <br />❑ 1 <br />❑ <br />❑ <br />❑ I❑ <br />❑ <br />❑ <br />I ❑ I <br />❑ I <br />Vapor Pot evac chase line <br />® <br />❑ <br />❑ 1 <br />❑ <br />UDC 1/2 <br />® <br />❑ <br />I ❑ 1 <br />87 Syphon Line <br />® <br />❑ <br />❑ <br />❑ <br />UDC 3/4 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 5/6 <br />® <br />❑ <br />❑ <br />❑ <br />87 Master Annular <br />® <br />❑ <br />❑ <br />❑ <br />UDC 7/8 <br />® <br />❑ <br />❑ <br />❑ <br />87 Syphon Annular <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Annular <br />® <br />❑ <br />❑ <br />❑ <br />87 Product Line <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Product Line <br />® I <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El— <br />if <br />If hydrostatic testing was performed, describe what was done with the water after <br />completion of tests: <br />Testina water stored in barrels onsite <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 />� J - <br />Technician's Signature: G� Date: 5/16/12 <br />• <br />