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SWRCB,January 2002 Page 1. <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 <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: ARCO #05450, CC 18022647 DateofTesting: 08/05/2008 <br /> Facility Address: 1617 W. FREMONT , STOCKTON, CA, 95205 <br /> Facility Contact: DEALER/MANAGER Phone: (2 0 9) 462-1617 <br /> Date Local Agency Was Notified of Testing: 07/16/2008 <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DENNIS RUE <br /> Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: ICC License Number: 5246067-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKETS 01/08/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repair <br /> Tested Made p Tested Made <br /> Spill Box 1 PRE FILL ❑ ® ® ❑ ® ❑ ❑ <br /> Spill Box 2 REG FILL ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> Spill Box 3 REG FILL Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ El ❑ ElF-1El❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br /> El ❑ I ❑ El El F-10 ❑ <br /> ❑ ❑ E] ❑ ❑ ❑ I ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PUT IN ON SITE DRUM. <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: ,�`' Date: 08/05/2008 <br />