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SWKB,January 2002 Page_l_of—2 <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 /> Facility Name: ARCO#02133 Date of Testing: 912/2011 <br /> Facility Address: 2908 BENJAMIN HOLT DRIVE,STOCKTON, CA 95207 <br /> Facility Contact: RICH GOSSETT I Phone: (714) 670-3958 <br /> Date Local Agency Was Notified of Testing: x/2091 <br /> Name of Local Agency Inspector(af present during testing): NONE PRESENT <br /> . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK TEK ENWRONMENTAL CORP. <br /> Technician Conducting Test: RICHARD THOMAS <br /> Credentials: ®CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: A (CSLB Lie.) License Number: 803705(CSLB Lic.) -- 06-167 ((SWRCB Lic) <br /> Manufacturer Training <br /> Manufacturer C®" onent(s) Date Traini x fires <br /> /CC CA UST SERVICE TECHNICIAN#5254736-UT DEC 28, 12 <br /> SC CB TANK TESTER LICENSE#06-1672 JUN 30,2012 <br /> FRANKLIN FUELING INCON SUMP TESTEj2#5012133701 FEB 8,2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Feil Tested Made <br /> LTC SUMP ® ElEl ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑i ❑ <br /> El El El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑, ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ M ❑, ❑ <br /> ❑ ❑ ❑ ❑ ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ El ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: 2f <br /> 1 2011 <br />