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SWRCB,January 2002 Page 1 of I <br /> Secondary Containment Testing Report Form <br /> This form is intended far use by contractors performing periodic testing of UST secondary containmen!''��i!1�('� e <br /> ly <br /> pages of this form to report results for all components tested. The completed form,written test procedurell r�i^7�i/t <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION MAY 01 2014 <br /> Facility Name:TRACY PETRO jDate of Testing:4/7/2014 <br /> Facility Address:3400N.MACARTHUR DR ,TRACY,CA 95376 <br /> Facility Contact:KARAM SINGH Phone:209-814-8581 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):not presant <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/162014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe Test(Tank Tl-premium) x <br /> Secondary Pipe Test(Tank T2-regular) x <br /> Secondary Pipe Test(Tank T3-diesel) x <br /> STP Containment for Tank TI premium-I x <br /> STP Containment for Tank T2 regular-1 x <br /> STP Containment for Tank T3 diesel-1 x <br /> UDC 4 1/2 x <br /> UDC At 3/4 x <br /> UDC M 5/6 x <br /> UDC k 7/8 x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken/recycled water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIRS TESTING <br /> To the best of my knowledgetheeffacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: d,t� Date: 4/7/2014 <br /> WO:2317562 <br />