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I <br /> SWRCB..lanuary 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing ul LST sec•ondary c•ontainme t systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, u•ritt n test procedures. and <br /> printouts from tests(if applicable),should be provided to the facility owner operatorfor submittal to he local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO # 06020, CC 18022765 Date ot"Testing: 08/22/2006 <br /> Facility Address: 1711 E YOSEMITE MANTECA, CA, 95336 <br /> Facility Contact: MANAGERPhone: (209) 823-4715 <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: DOUGLAS HARTY <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date I raining L.,�pires <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-UL ❑ ❑x ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2-MID E ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3-PRE ❑x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ —j- <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 01 ❑ ❑ I ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ E . ❑ 1 ❑ 1 11:11 ❑ ❑ ❑ <br /> I f hydrostatic testing was performed.describe what was done with the water atter completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THiS TESTING <br /> To the best of rrty knowledge, the facts stated in this document are accurate and in fill compliance with legal requirements <br /> Technician's Signature: r<--�. '" �: Date: 08/22/2006 <br />