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SWRCB,January 2002 SEP 2 2 2016 Page_1_of_7_ <br /> Secondary Containment Testing Repm*Rq Eun„ <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(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 1 Date of Testing: 519116 <br /> Facility Address: 3212 N CALIFORNIA,STOCKTON, CA 95204 <br /> Facility Contact: SARAH SAMUELS I Phone: (360)371-8111 <br /> Date Local Agency Was Notified of Testing: 4122116 <br /> Name of Local Agency Inspector(rf present during testing): NONE PRESENT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORP. <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials: ®CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: A (CSLB Lic.) License Number:803705(CSLB Lic)— 06-1672(SWRCB Lic) <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC CA UST SERVICE TECHNICIAN#5254736 DEC 5, 2016 <br /> SCWRCB TANK TESTER LICENSE#06-1672 JUNE 30, 2018 <br /> FRANKLIN FUELING INCON SUMP TESTER#5012133701 FEB 10, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87(1)TANK ANNULAR ® ❑ ❑ ❑ UDC#1/2 ® ❑ ❑ ❑ <br /> 87(1)PRODUCT SECONDARY ® ❑ ❑ ❑ UDC#314 ® ❑ ❑ ❑ <br /> 87(1)STP SUMP ® ❑ ❑ ❑ UDC#5/6 ❑ ® ❑ ❑ <br /> 87(1)FILL SUMP ® ❑ ❑ ❑ UDC#7/8 ® ❑ ❑ ❑ <br /> 87(2)TANK ANNULAR ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87(2)SYPHON LINE ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87(2)STP SUMP ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> 87(2) FILL SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 TANK ANNULAR ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 PRODUCT SECONDARY ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 FILL SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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:_ v v`�J Date: 5/9/2016 <br />