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r <br />SWRCB, January 2002 <br />LJ <br />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 (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 />DateofTesting: 12/18/2007 <br />Facility Address: 3425 TRACY BLVD , TRACY, CA, 95376 <br />Facility Contact: MANAGER I Phone: (2 0 9) 835-1605 <br />Date Local Agency Was Notified of Testing: 12/02/2007 <br />Name of Local Agency Inspector (if present during testing): RAY VON FLUE <br />2. TESTING CONTRACTOR IN1' / <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />DENNIS RUE <br />Component <br />Credentials: <br />❑ <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: I CC <br />Manufacturer <br />I License Number: 5246067 -UT <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />PHILTITE <br />SPILL BUCKETS <br />03/24/2008 <br />�LL <br />:. ! <br />a000 <br />0000 <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />PUT IN ON SITE DRUM. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated <br />in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 'g— - �'" �'" Date: 12/18/2007 <br />Component <br />SSSpp <br />�LL <br />:. ! <br />a000 <br />0000 <br />. :. <br />0000 <br />_ _ _ <br />0000 <br />Spill Box 4 REG FILL <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />■�■0000� <br />0000 <br />0000 <br />0000� <br />■�0000 <br />�'■ <br />0000 <br />0000 <br />0000 <br />000��■�■����■0000 <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />PUT IN ON SITE DRUM. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated <br />in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 'g— - �'" �'" Date: 12/18/2007 <br />