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SWRCB, January 2002 <br />Page of <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 thisform 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 />Facility Name: ARCO # 82602 1 Date of Testing: 10/12/2017 <br />Facility Address: 2430 Joe Pombo Pkwy. Tracy, CA 95376 <br />Facility Contact: Vikram I Phone: (209) 247-6061 <br />Date Local Agency Was Notified of Testing: 10/5/2017 <br />Name of Local Agency Inspector (f present during testing): <br />Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />2. TESTING CONTRACTOR INFORMATION <br />4 <br />Company Name: Diamond Petroleum Services, Inc. <br />Pass Fail <br />Technician Conducting Test: <br />Guadalupe Sanchez <br />Pass <br />Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />Repairs <br />Made <br />License Type: <br />Manufacturer <br />A License Number: 1005444 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Caldwell Systems <br />Level Change Indicator <br />May 2018 <br />Veeder Root <br />TLS -350 <br />11/2/2017 <br />ICC <br />Service Tech <br />4/8/2019 <br />❑ ❑ <br />❑ <br />STP Sump Tank #1 87 Master <br />ka <br />Component <br />Pass Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #187 Master <br />x ❑ <br />❑ <br />0 Fill Sump Tank #3 91 <br />x <br />❑ ❑ <br />❑ <br />Annular Tank #2 87 S/91 <br />x 0 <br />❑ <br />0 UDC 1&2 <br />x <br />❑ ❑ <br />❑ <br />STP Sump Tank #1 87 Master <br />x ❑ <br />❑ <br />❑ UDC 3&4 <br />x <br />❑ 1 ❑ <br />❑ <br />STP Sump Tank #2 87Syphon <br />x 0 <br />❑ <br />❑ UDC 5&6 <br />x <br />0 ❑ <br />0 <br />STP Sump Tank #3 91 <br />x 0 <br />❑ <br />❑ UDC 7&8 <br />x <br />❑ ❑ <br />0 <br />Secondary Pipe #187 Master <br />x ❑ <br />❑ <br />❑ UDC 9&10 <br />x <br />❑ ❑ <br />❑ <br />Secondary Pipe #2 87 Syphon <br />x ❑ <br />❑ <br />❑ UDC 11&12 <br />x <br />❑ ❑ <br />❑ <br />Secondary Pipe #3 87M to 91 <br />x ❑ <br />0 <br />0 <br />❑ ❑ <br />❑ <br />Secondary Pipe#4 87S to 91 <br />x ❑ <br />❑ <br />0 <br />❑ <br />❑ ❑ <br />❑ <br />Secondary Pipe #5 91 <br />x ❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Fill Sump Tank #187 Master <br />x ❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Fill Sump Tank #2 87 Syphon <br />x ❑ <br />❑ <br />❑ <br />❑ <br />❑ 0 <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed water into 55 gal steel drums located on site. <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:/..,�a� � --ift4r Date: 10/12/2017_ <br />