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C <br />SWRCB, January 2002 <br />11 <br />Page 1. <br />Secondary Containment Testing Report Form <br />Thisform 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 # 02093 CC18022760 <br />Date of Testing: 11/26/2008 <br />Facility Address: 3425 TRACY BLVD TRACY, CA, 95376 <br />Facility Contact: MANAGER <br />Phone: (209) 835-1605 <br />Date Local Agency Was Notified of Testing : / / <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: <br />DENNIS RUE <br />Credentials: <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />ispill Box 1 PRE FILL <br />License Type: ICC <br />Manufacturer <br />License Number: 5246067 -UT <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />PHILTITE <br />SPILL BUCKETS <br />12/17/2009 <br />:;Spill Box 2 REG FILL <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Component <br />ispill Box 1 PRE FILL <br />:;Spill Box 2 REG FILL <br />�Spill Box 4 REG <br />000 <br />��00' <br />00oo <br />a000 <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: .?' Date: 11/26/2008 <br />