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SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This/brie is intendedfor use by contractors performing periodic testing of USTsecondary 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(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 #02186, CC 18022645 DateofTesting: 02/23/2010 <br /> Facility Address: 3212 N. CALIFORNIA @ ALPINE AVE. PTO # N-79, STOCKTON, CA, 95210 <br /> Facility Contact: MGR - KEVIN Phone: (209) 941-2694 <br /> Date Local Agency Was Notified of Testing: 02/09/2010 <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: El CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH I License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 11/04/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 REG FILL ❑ ❑ ❑ 0 E <br /> Spill Box 1 REG FILL E-1], ❑ ❑ ❑ El El El El <br /> Spill Box 2 REG FILL El ❑ ❑ 0 <br /> Spill Box 3 PRE FILL El ❑ ❑ El <br /> El I El El El <br /> El I El <br /> El I El El El Ell 1:11 1 <br /> El I El I El E] ❑ <br /> El El El El El El I <br /> El El El 1:1 <br /> El 1:1 1:1 E <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WAST DRUM ONSITE. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts started in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 4 l Date: 02/23/2010 <br />