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• SWRCB,January 2002 • • Page 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 <br /> appropriate pages of this form to report results for all components tested The completed form,written test procedures,and <br /> printouts from tests(rf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: ARCO/B.P. # 9600, CC 18022603 Dateof Testing: 04/19/2006 <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 Agency Inspector(if 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 Tester <br /> License Type: License Number: <br /> Manufacturer Training <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 /> Spill Box 1-87 ❑X ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> Spill <br /> Spill Box 2-89 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3-91 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ <br /> ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the fagcts_stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: l�tS�lr/"� Date: 04/19/2006 <br />