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SWRCB, January 2002 Page _1_ of _8_ <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. FA(..1I,TTY1FNF0RMAT1(1N <br />Facility Name: ARCO #02133 <br />Date of Testing: 412912011 <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: 41812011 <br />Name of Local Agency Inspector (ifpresent during testing): <br />Company Name: TANK-TEK ENVIRONMENTAL CORP. <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />License Type: A (CSLB Lic.) License Number: 803705 (CSLB Lie.) -- 06-1672 (SWRCB Lic.) <br />MENERINOM <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />ICC CA UST SERVICE TECHNICIAN #5254736 -UT DEC 28, 2012 <br />SCINRCB TANK TESTER LICENSE #06-1672 JUN 30, 2012 <br />FRANKLIN FUELING INCON SUMP TESTER #5012133701 FEB 8, 2013 <br />MEMO livi EA AN &IN-111MY90 <br />- ----- ---- — <br />Component <br />87(l) TANK ANNULAR <br />87(l) TLM SUMP <br />87(l) PRODUCT SECONDARY <br />PRODUCT PIPING SUMP <br />87(1) STP SUMP <br />87(1) FILL SUMP <br />=/ <br />ova <br />►, <br />oc�o <br />KO <br />PRDUCT SECONDARY <br />// <br />o00 <br />� �3 <br />oMM <br />87(2),STP SUMP <br />o00 <br />87(2) FILL SUMP <br />87(l) VAPOR BUCKET <br />// <br />��� <br />PRODUCT SECONDARY <br />_/ <br />oo <br />; VAPOR : <br />91(3) STP SUMP <br />91(3) FILLo00�� <br />o00 <br />• <br />1/ <br />II, <br />MMM <br />II, <br />II,� <br />• ---_ VAPOR BUCKET <br />___-_ -_-__- --_- <br />�,_ <br />■.._ <br />•.-. <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TEST WATER WAS DRUMED UP INTO p5 GALLON DRUMS — LEFT 9 DRUMS ON <br />CERTIFICATION OF I <br />To the best of my knowledge, the facts <br />Technician's Signature:`" <br />OCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />in this document are accurate and in full compliance with legal requirements <br />Date: 4/29/2011 <br />