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SWRCB,January 2002 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 DateofTesting: 12/29/2009 <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: 11/24/2009 <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY REHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: E CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH. License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> PHIL TITE SPILL BUCKET 11/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 UNL FILL M ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 UNL FILL X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 UNL FILL F,--1 ❑ ® ❑ ❑ ❑ ❑ <br /> Spill Box 4 PRE FILL ❑ ❑ ❑ El El 0 <br /> ❑ ❑ 1 ❑ ❑ DI ❑ ❑ <br /> El ❑ ❑ El F ❑ M <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El 1:1 ❑ ❑ El El <br /> El E] <br /> 1:1 . 1:1 , 1:1 1011:110 101 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WASTE DRUM ONSITE. <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: _ l�� Date: 12/29/2009 <br />