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Page of_��_. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, I M ZT81 1 A II 16A 1.1 Z#7 -"Tr, YVr • . Facility Name: Arco 5469 1 Date of Testing: 3/18-19/03 Facility Address: 130 So_ Wilson Way Stockton Ca. 95204 Facility Contact: Jaqueline Williamson I Phonc: Date Local Agency WaS Notified of Testing : 3/11/03 Naive of Local Agency inspector Present: Nonc Present 2_ TESTING CONTKA,CTOR INFORMATION Company Name: SJ Weaver Cmitracting 111c. 0 Technician Conducting Test: Randy Littlefield Number of Piping Runs Tested: 0 Credentials: X CSL13 Licensed Contractor ❑ SWRC13 Licensed Tank Tester Sumps Tested: License Type and ti: A, Tian, D Lic4 717173 Number of UDC; Boxes Tested: 1 Training by Manufacturer Manu 4durer Component s Date Traininp, Ux ires 1NCON Sumps. UDC's 9/l/04 AO Smith Secondary Piping 6/1/03 Environ Secondary Piping 6/1./03 X n 3. SUMMARY OF TEST RESULTS Number of Tanks Tested: 0 Number of Piping Runs Tested: 0 NumbYT of Submersible ?ump Sumps Tested: 3 Number of UDC; Boxes Tested: 1 Number of bill Suinps Tcsted: 0 Numbcr of Overfill Boxes Tested: 3 Component Paste Fail Comments 87 turbine sump X n 89 turbine sump X F1 LL 91 turbine sump X ❑ 87 spill bucket X I.I 89 spill bucket X ❑ 91 spill bucket X ❑ UDC11-12 X I"I ❑ ❑ ❑ ❑ 11 0 ❑ ❑ 'AlSpre testing must utilize an Inert gas. f Technician's Signature: R,C.U,S.T,COM 'Date: December 2001