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SWRCB.Januar 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> T his farm is intended for use by contractors performing periodic testing ol.(.'S7'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 /> printoutsfi•om tests(if applicable), should he provided to the facility owner operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO #02186, CC 18022645 DateofTesting: 10/03/2006 <br /> Facility Address: 3212 N. CALIFORNIA PTO # N-79, STOCKTON, CA, 95210 <br /> Facility Contact: MGR - KEVIN Phone: (209) 941-2694 <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: DENNIS RUE <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 /> Made <br /> Spill Box 1 REG FILL E ❑ ❑ ❑ ❑ ❑ ❑ F-1- <br /> Spill <br /> Spill Box 1 REG FILL FRI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 REG FILL x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 PRE FILL ❑ El ❑ El ❑ ❑ ❑ ❑ <br /> El El El E] El 0 <br /> D D El El E <br /> E E El El El El <br /> El I E] El El El 1:1 El E <br /> El I El El El El El <br /> El- <br /> El El El 0 <br /> El <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 facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 'g- Date: 10/03/2006 <br />