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1 <br /> SWRC13,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,a t rom tests(if <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency <br /> 1.FACILITY INFORMATION EIVED <br /> Facility Name:MARCH LANE 76 jDate of Testing:4/23/2014 n <br /> Facility Address: 1206 E.MARCH LANE ,STOCKTON,CA 95210 >, <br /> Facility Contact:KARAM SINGH Phone:510-926-7834 <br /> Date Local Agency Was Notified of Testing: HFA <br /> Name of Local Agency Inspector(if present during testing):jeff wong <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: 7 CSLB Licensed Contractor r— S WRCB Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/16/2014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular#3 x UDC#6/ x <br /> Tank Annular#2 X UDC#7/8 x <br /> Tank Annular#I x UDC#9/10 x <br /> Secondary Pipe Test(Tank 3-diesel) X <br /> Secondary Pipe Test(Tank 2-premium) x <br /> Secondary Pipe Test(Tank I-regular) x <br /> STP Containment for Tank 3 diesel-I x <br /> STP Containment for Tank 2 premium-1 x <br /> STP Containment for Tank 1 regular-1 x <br /> UDC#1/2 x <br /> UDC#3/4 x <br /> UDC#5/ 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 THIS TESTING <br /> To the best of my knowledgee,tthe�fac�ts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 1%?-- Date: 4/23/2014 <br /> WO:2317860 <br />