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I 1 0 <br />SWRCB, January 2002 • Page _1_ of_9_ <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 (lf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ARCO #2093 Date of Testing: 3/19/2015 <br />Facility Address: 3425 TRACY BL VD, TRACY, CA 94376 <br />Facility Contact: SARAH SAMUELS Phone: (360) 371-8111 <br />r <br />Date Local Agency Was Notified of Testing: 3/4/15 `-- <br />Name of Local Agency Inspector (f present during testing): NONE PRESENT W1.1 V ;;, <br />2. TESTING CONTRACTOR INFORMATION APR 2 0 2ni� <br />Company Name: TANK-TEK ENVIRONMENTAL CORP. <br />Pass <br />Technician Conducting Test: <br />RICHARD THOMAS <br />°", 4 <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />Pass <br />License Type: <br />A (CSLB Lic.) License Number: 803705 (CSLB Lic.) -- 06-1672 (SWRCB Lic) <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />ICC _ <br />CA UST SERVICE TECHNICIAN #5254736 <br />DEC 5, 2016 <br />SCWRCB <br />TANK TESTER LICENSE #06-1672 <br />JUN 30, 2015 <br />FRANKLIN FUELING <br />INCON SUMP TESTER #5012133701 <br />FEB 01, 2017 <br />0 <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87(1) TANK ANNULAR <br />® <br />❑ <br />❑ <br />❑ <br />91 TANK ANNULAR <br />® <br />❑ <br />❑ <br />❑ <br />87(1) PRODUCT SECONDARY <br />0 <br />❑ <br />❑ <br />❑ <br />91 PRODUCT SECONDARY <br />® <br />❑ <br />❑ <br />❑ <br />87(1) STP SUMP <br />® <br />❑ <br />❑ <br />❑ <br />91 STP SUMP <br />® <br />❑ <br />❑ <br />❑ <br />87(1) FILL SUMP <br />® <br />❑ <br />❑ <br />❑ <br />91 FILL SUMP <br />® <br />❑ <br />❑ <br />❑ <br />87(2) TANK ANNULAR <br />® <br />❑ <br />❑ <br />❑ <br />UDC #1/2 <br />® <br />❑ <br />❑ <br />❑ <br />87(2) PRODUCT SECONDARY <br />❑ <br />❑ <br />❑ <br />UDC #3/4 <br />® <br />❑ <br />❑ <br />❑ <br />87(2) STP SUMP <br />❑ <br />❑ <br />❑ <br />UDC #5/6 <br />® <br />❑ <br />❑ <br />❑ <br />87(2) FILL SUMP <br />® <br />❑ <br />❑ <br />❑ <br />UDC #7/8 <br />® <br />❑ <br />❑ <br />❑ <br />87(3) TANK ANNULAR <br />® <br />❑ <br />❑ <br />❑ <br />87(1) FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />87(3) SYPHON PRODUCT SEC _ <br />® <br />❑ <br />❑ <br />❑ <br />87 1) VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />87(3) STP SUMP <br />® <br />❑ <br />❑ <br />❑ <br />87(2) FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />87(3) FILL SUMP <br />® <br />❑ <br />❑ <br />❑ <br />87(2) VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT 4 LABELED 55 GALLON DRUMS ON SITE FOR LATER PICK UP <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 U�—s Date: 3/19/15 <br />