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i 0 RECEIVED <br />Secondary Containment Testing Report Form NOV 16 2015 <br />This Porn: is intended for use by contractors performing periodic testing of U.ST secondary containment s'ttstems. Use th <br />appropriate pages of this form to report results for all components tested The completed form, writ <br />printouts from tests (if applicable), should be provided to the facility owner/operator,for submittal toih <br />V4 �'a�tt free y. <br />F A PIT T•rV TrO e-InAN A rrBreiar <br />Facility Name: ARCO <br />Date of Testing: 10/1/2015 <br />Facility Address: 880 E VICTOR RD, LODII.. <br />County SAN JOAQt IN <br />Facility Contact: KARAN <br />Phone: 209-369-0958 <br />Date Local Agency Was Notified of Testing : <br />Wednesday, September 30, 2015 <br />Name of Local Agency Inspector (if present during testing): <br />ARIS VELOSO <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: B.Z. Service Station Maintenance <br />Technician Conducting Test: JERAMY CUMMINS <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: ICC License Number: 433159 <br />Manufacturer Training <br />Manufacturer Component(s)) Date Trainine <br />INCON TS -STS 8/1/20 <br />';_ CIIMMARV n1 TVQ9r taUC1TT 'rC <br />u nyarostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK AS TEST 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 witlt legal require, Pients <br />Technician's Signature: Date: 10/1/2015 <br />Secondary Containment Test Results 1 nf'? <br />0000 <br />as <br />c•� <br />000© <br />oo <br />a <br />oc•�oo <br />c�c•� <br />o <br />0000 <br />as <br />a <br />c■�c•�oc■� <br />oc■� <br />v <br />c•�oc•�r•� <br />cir•� <br />c■� <br />oc•�o■r■� <br />oc� <br />o <br />0000 <br />00 <br />0 <br />u nyarostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK AS TEST 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 witlt legal require, Pients <br />Technician's Signature: Date: 10/1/2015 <br />Secondary Containment Test Results 1 nf'? <br />