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r • • SWRCB,January 2002 Page J of 13 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Tracy Truck&Auto I Date of Testing: Facility Address: 3940 North Tracy Blvd., Tracy CA 95304 Facility Contact: Debbie Jutla Phone: 209-832-5006 2015 Date Local Agency Was Notified of Testing: 09/09/2015 NI Name of Local Agency Inspector(f present during testing): Michelle Henry PEgM H�,q� 2. TESTING CONTRACTOR INFORMATION Company Name: Central Petroleum Maintenance Technician Conducting Test: Michael Spring Jr. Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed,rank Tester License Type: C61/1340 License Number: 491948 Manufacturer Training Manufacturer Component(s) Date Training Expires Incon TS-STS Sump Test System 06/12/2015 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made T1/2 - 87/91 tank Annular X ❑ ❑ ❑ Diesel East Hi-flow STP.sump X ❑ ❑ ❑ T3 Diesel West Tank Annular X ❑ ❑ ❑ El T4 Diesel East Tank Annular X ❑ ❑ ❑ Diesel West Hi-flow STP X ❑ ❑ ❑ 87 secondary pipe X ❑ ❑ ❑ AST piping sump X ❑ ❑ ❑ 91 secondary pipe X ❑ ❑ ❑ #1/2 UDC X ❑ ❑ ❑ Dsl West spcondaxpipe. p ❑ ❑ #3/4 UDC X ❑ ❑ ❑ Dsl East siphon secondary pipe X ❑ ❑ ❑ #5/6 UDC X ❑ ❑ ❑ Dsl East hi-flow secondary pipe X ❑ ❑ ❑ #7/8 UDC X ❑ ❑ ❑ 1Dsl.West 4low$.MQ44=y pipe El a ❑ #9A UDC X ❑ ❑ ❑ 87 STP sump X ❑ ❑ ❑ 49/10A UDC X ❑ ❑ ❑ 91 STP sump X ❑ ❑ ❑ #10/11A UDC X ❑ ❑ ❑ Diesel siphon sump X ❑ ❑ ❑ #11/12A UDC X ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test water placed in drums and removed for re-use as test water. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements J5 Technician's Signature:,, -- Date: