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j 4 0 SWRCB,January 2002 Page of 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 Date of Testing: 4/3/2015 Facility Address: 3940 North Tracy Blvd., Tracy CA 95304 Facility Contact: Debbie Jutla I Phone: 209-832-5006 Date Local Agency Was Notified of Testing: 04/01/15 Name of Local Agency Inspector(f present during testing): Michelle Henry 4 MA IND 2. TESTING CONTRACTOR INFORMATION 2015 Company Name: Central Petroleum Maintenance OTAI Liz--NME Technician Conducting Test: Michael Spring Jr. T/SERV H Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type:C61/D40 License Number: 491948 Manufacturer Training Manufacturer Components Date Training Expires Incon TS-STS Sump Test System 08/12/2015 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Diesel West Secondary X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel West Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 0 ❑ ❑ ❑ ❑ 0 ❑ 0 0 ❑ ❑ 0 ❑ ❑ ❑ ❑ 0 ❑ 0 0 0 0 0 ❑ ❑ ❑ 0 0 ❑ ❑ ❑ 0 ❑ ❑ 0 0 0 r7 ❑ ❑ ❑ ❑ 0 0 0 ❑ 0 ❑ 0 ❑ 0 ❑ 0 ❑ 0 ❑ ❑ 0 0 ❑ 0 ❑ ❑ ❑ 0 0 0 ❑ 0 ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test water placed in drums and removed for 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 Technician's Signature: � w, Date: /�