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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of I <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. RECEIVED <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Timothy Elebeck <br />Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: ice License Number: 8001435 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />phi] tite sb 3/22/2015 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box T I premium fill <br />X <br />Spill Box T 2 regular fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />water was taking 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 with legal requirements <br />Technician's Signature: `11, `9 Date: 3/3/2014 <br />WO: 2315878 <br />