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SWRCB, January 2002 Page 1 of 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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts fi4om tests (if <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: ARCO 02076, CC 18022641 Date of Testing: 12/ 13/2018 <br /> Facility Address : 800 KETTLEMAN LN PTO N-85, LODI, CA 95240 <br /> Facility Contact: MANGER Phone: 209-334-3678 w <br /> Date Local Agency Was Notified of Testing: t <br /> Name of Local Agency Inspector (if present during testing) : unknown X <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY INC. <br /> Technician Conducting Test: Jarrod Cooke ` ' <br /> ` <br /> Credentials : W` CSLB Licensed Contractor riA SWRCB Licensed Tank Tester ' ; 11 <br /> License Type : a License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 4/26/2020 <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Nbde <br /> Tank Annular# tl x STP Containment for Tank t4 supreme - I X <br /> Tank Annular# T-2 x UDC # 1 /2 X <br /> Tank Annular# T-3 x UDC # 3/4 x <br /> Tank Annular# t4 X UDC # 5/6 x <br /> Secondary Pipe Test (Tank tl - reg unlead) X UDC # 7/8 X <br /> Secondary Pipe Test (Tank tl - reg unlead) X Fill Containment for Tank: t reg unlead - 1 X <br /> Product Pipe for reg 1 to reg 2 x Fill Containment for Tank: T-2 regular - 1 X <br /> i <br /> Product Pipe for reg 1 to reg 3 X Fill Containment for Tank: T-3 regular - I X <br /> t <br />(z <br /> Secondary Pipe Test (Tank t4 - supreme) X Fill Containment for Tank: t4 supreme - 1 X <br /> k STP Containment for Tank tl reg unlead - 1 X <br /> f <br /> t STP Containment for Tank T-2 regular - 1 X <br /> STP Containment for Tank T-3 regular - 1 X <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests : <br /> taken water trailer <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 : e Date : 12/13/2018 <br /> WO : 2339260 <br /> i <br />