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SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <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 /> FacilityName: ARCO # 06020, CC 18022765 1 DateofTesting: 09/12/2008 <br /> Facility Address: 1711 E YOSEMITE , MANTECA, CA, 95336 <br /> Facility Contact: MANAGER I Phone: (2 0 9) 823-4715 <br /> Date Local Agency Was Notified of Testing: 09/02/2008 <br /> Name of Local Agency Inspector(if present during testing): MUNIAPPA NAIDU <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH. License Number: 5259458-UT <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 01/18/2010 <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 1fl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 MID FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 PRE FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑ I ❑ ❑ ❑ <br /> ❑ El <br /> ❑ ❑❑ <br /> ❑❑ ❑ ❑ I ❑❑ ❑❑ ❑❑ <br /> El El El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WASTE DRUM ONSITE. <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: I t/"' Date: 09' /12/2008 <br />