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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(f applicable), should be provided to the.facility ownerloperator.for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO/B.P. # 5469, CC 18022648Date of Testing: 04/18/2006 <br /> Facilitv Address: 130 S. WILSON WAY STOCKTON, CA, 95205 <br /> Facility Contact: MANAGER Phone: (209) 466-6633 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Compam 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 Hade <br /> Spill Box I-87 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2-89 X❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3-91 ❑ 1:1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1:]- <br /> 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ I ❑ I I ❑ I Ell ❑ I ❑ <br /> I 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 facts stated in this document are accurate and infill compliance with legal requirements <br /> Technician's Signature: lt/"' Date: 04/18/2006 <br />