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SWRCB,January 2002 RECEID <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use tp rig(etd <br /> pages of this form to report results for all components tested. The completed form,written test procedures,and printodfs JM'orDl t�st.�li <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. ENVIRONMENTAL <br /> 1. FACILITY INFORMATION <br /> Facility Name:TRACY PETRO Date of Testing:2/2112014 <br /> Facility Address:3400 N.MACARTHUR DR ,TRACY,CA 95376 <br /> Facility Contact:KARAM SINGH Phone:209-814-8581 <br /> Date Local Agency Was Notified of Testing:2/21/2014 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Brent Bowen <br /> Credentials: r: CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:A ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> opw spill buckets 2/2/2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box TI premium fill X <br /> Spill Box T2 regular fill X <br /> Spill Box T3 diesel fill X <br /> FF <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> took test water with me <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TRIS TESTING <br /> To the best of my knowledge, <br /> ,thhee facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 2/212014 <br /> WO:2317099 <br />