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SWRCB, January 2002 Pae I of L Secondary Containment Testing Report Form Ii This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Us the appropriate pages of this form to report results for all components tested. The completed form, written test procedur s, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Tracy Truck & Auto Date of Testing: 10/12/2015 Facility Address: 3940 North Tracy Blvd., Tracy CA 95304 Facility Contact: Debbie Jutla Phone: 209-832-5006 Date Local Agency Was Notified of Testing: 04/01/15 Name of Local Agency Inspector (if present during testing): Michelle Henry , 2. TESTING CONTRACTOR INFORMATION Company Name: Central Petroleum Maintenance Technician Conducting Test: Michael Spring Jr. t itALTFi Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester Component License Type: C61/D40 License Number: 491948 Manufacturer Training Manufacturer Component(s) Date Training Expires Incon TS -STS Sump Test System 08/12/2015 MON 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test water placed in drums and removed for use as test water. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I To lire best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requht menu Technician's Signature: N/ l l l P�► Date: Component no Diesel West Secondary MON M1o. 0000 onia�a� 000a oo�ao 0000 000; oaoo ao�d� MM odoo na�o 0000 00�0� a000 a opo If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test water placed in drums and removed for use as test water. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I To lire best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requht menu Technician's Signature: N/ l l l P�► Date: