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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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: ARCO #06080, CC 18022649 DateofTesting: 09/17/2008 <br /> Facility Address: 85 E LOUISE AVE PTO N-71, LATHROP, CA, 95330 <br /> Facility Contact: MANGER I Phone: (2 0 9) 983-9144 <br /> Date Local Agency Was Notified of Testing: 08/11/2008 <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: DENNIS RUE <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I CC License Number: 5246067-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKETS 12/17/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairss <br /> Tested Made p Tested Made <br /> Spill Box 1 REG FILL M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PLU FILL EZI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 PRE FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E El E El <br /> El El D E El <br /> El El 0 El ElEl <br /> El El 1:1 El El <br /> El- <br /> D E El El 0 <br /> El- <br /> El El El El EJ E <br /> El El El El El <br /> El- <br /> El El El Eli El El <br /> El El E 1 01 01 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PUT IN ONSITE DRUM. <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: ,,��'. Z�,A Date: 09/17/2008 <br />