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Page I of 1 <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> tprinmuts ftom tests <br /> of t �rm to report resultsfor all components tested. The rsmm <br /> (if applicable), should be provided to thefaclity owner/operaorfoubmil the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing:2/25/2013 <br /> Facility Name:TRACY PETRO <br /> Facility Address:34001 MACARTHUR DR ,TRACY,CA 95376 phone:8148581 <br /> Facility Contact:KARAM SINGH <br /> Date Local Agency Was Notified of Testing 2/15/2013 <br /> Name of Local Agency Inspector(i( resent during testing): muni,claina,thuy <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steven Willems <br /> Credentials: rV CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type: a License Number:743160 <br /> Manufacturer Training <br /> Components) Datc Training Expires <br /> Manufacturer 10/162 I4 <br /> phil file spill bucket <br /> 3. SUMMARY OF TEST RESULTS <br /> Not epairNot Repairs <br /> Component Pass Fag este Made Component Pass Fail Tested Made <br /> spill Box TI premium fill X <br /> Spill Box T7 regular fill X <br /> Spill Boz T2 regular fill X <br /> Spill Box T3 diesel fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: put in bucket with lid and take <br /> with me <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TInS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> .. &-R➢ Date: 2/25/2013 <br /> Technician's Signature: <br /> WO:2310832 <br />