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S W RCB.Januar 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for ttse by contractors performing periodic testing of t'S7'secondary conlainmem systems. Use the <br /> appropriate pages of this form to report reszdts for all components tesled The completed farm, written test procedures. and <br /> printouts fi-one tests(f applicable), should be provided to the facility onncr operator for submitral to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO # 09600, CC 18022603 Dateol'Testing: 04/16/2007 <br /> Facility Address: 1250 N. WILSON WAY STOCKTON, CA, 95205 <br /> Facility Contact: MANAGER Phone: (209) 465-5359 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Auency Inspector(it present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank"fester <br /> License Type: I License Number: <br /> Manufacturer TraininE <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Made <br /> Spill Box 1 REG FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 MID FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 SUP FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ej <br /> El Ej El El EjI El E <br /> Ej El E El El El El <br /> El El E1 El El El El <br /> El El El El El El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E El I n El El El <br /> El <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the fa//ct_s stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 41' lrl— Date: 04/16/2007 <br /> /7 <br />