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SWRCB,January 2002 ;Page_1_of_2 Secondary Containment Testing Report For This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local rejulatory agency. 1. FACILITY INFORMATION Facility Name: ARCO#02133 Date of Testing: 9?J2019 Facility Address: 2908 BENJAMIN HOLT DRIVE,STOCKTON, CA 95207 Facility Contact: RICH GOSSETT Phone: (714)670-3958 Date Local Agency Was Notified of Testing: 81212011 Name of Local Agency Inspector(cf present during testing): NONE PRESENT 2. TESTING CONTRACTOR INFORMATION Company Name: TANK TEK ENVIRONMENTAL CORP. Technician Conducting Test: RICHARD THOMAS Credentials: ®CSLB Licensed Contractor ®SWRCB Licensed Tank Tester License Type: A (CSLB Lic) License Number: 803705(CSLB Lic.)'-- 06-16721(SWRCB Lie) Manufacturer Training Manufacturer Com nent(s) Date Trainin Expires ICC CA UST SERVICE TECHNICIAN#5254736-UT DEC 28,2012 SC RCB TANK TESTER LICENSE#06-1672 JUN 30,,2012 FRANKLIN FUELING INCON SUMP TESTER#15012133701 FEB 8,2013 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component pass Feil Not,TRairs epTested Made TestedMade LTC SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ s ❑ ❑ ❑ ❑ ❑ ❑ ❑' ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El El 1:1El El El El 11 0 El El El 13 ❑ F1v. Cl ❑ El F1El ❑ ' ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,thefacts stated in thisidocument are accurate and in full compliance with legal requirements Date 91212011 Technician's Signature: