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SWRC13..Ianuar\ 2002 <br />Secondary Containment Testing Report Form <br />Page 1. <br />This form is intended for use by contractors performing periodic testing of LST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed.favn. written test procedures, and <br />printouts from tests (if applicable, should be provided to the facility owner operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ARCO # 05469, CC 18022648 (N86) <br />Date of Testing: 02/14/2007 <br />Facility Address: 130 S. WILSON WAY STOCKTON, CA, 95205 <br />Facilitu Contact: MANAGER <br />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 />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />KELVIN CRUZ <br />Credentials: <br />d <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: <br />License Number: <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Box 2 MID FILL <br />. Box <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing \x as 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 in fill compliance with legal requirements <br />O, <br />Technician's Signature: Date: 02/14/2007 <br />RIM <br />d <br />Spill Box 1 REG FILL <br />Box 2 MID FILL <br />. Box <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />If hydrostatic testing \x as 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 in fill compliance with legal requirements <br />O, <br />Technician's Signature: Date: 02/14/2007 <br />