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` w <br /> S <br /> SWRCli..lanuan 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> 77tis161-111 is intent('(!for use by contractors perfa•rning periodic testing q/�t.,ST secondary containin nt s'vstems. Use the <br /> appropriate pages ofthisform to report results,for all components tested. The completed,form, writ en test procedures, and <br /> printouts fr'on1 tests(if applicahle). sljould he provided to the f icili{y owner operator for submittal It the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO # 06020, CC 18022765 Date of resting: 10/18/2006 <br /> Facility Address: 1711 E YOSEMITE MANTECA, CA, 95336 <br /> Facility Contact: MANAGER Phone: (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: DENNIS RUE <br /> Credentials: 0 CSLB Licensed Contractor D SWRCB Licensed Tan 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 Made <br /> Spill Box 1 UNL FILL ❑X D gEE <br /> 0 0 0 <br /> 0 0 0 0 <br /> 0 0 0 00 ❑ El ❑ El El ❑El ❑ 0 El 0 ❑ ❑ <br /> 0 0I 0 0 0 <br /> 0 0 0 0 0 0 0 El- <br /> 0 <br /> 0 0 0 l 0- 0 Eli 0 0 <br /> F711 01 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 <br /> 0 1:110 I 0 0 0 El 0 <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:'"' Date: 10/18/2006 <br />