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' SWRCI4, January 2002 <br />Page _2_ 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />11- FACILITY INFORMATION <br />Facility Name: ARCO #02093 Date of Testing: 41312012 <br />Facility Address: 3425 TRACY BLVD, TRACY, CA 95376 <br />Facility Contact: RICH GOSSETT Phone: (714) 670-3958 <br />Date Local Agency Was Notified of Testing: 3120/2012 <br />Name of Local Agency Inspector (fpresent during testing): NONE PRESENT <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 />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />ICC CA UST SERVICE TECHNICIAN #5254736 -UT DEC 28, 2012 <br />SCWRCB TANK TESTER LICENSE #06-1672 JUN 30, 2012 <br />FRANKLIN FUELING INCON SUMP TESTER #5012133701 FEB 8, 2013 <br />05 105 V.A 6141all <br />Component <br />MUM <br />` • - BUCKET <br />► <br />DO�: <br />00�� <br />FILL BUCKET <br />► <br />DD�i <br />000 <br />VAPOR BUCKET <br />a <br />„ <br />o0 <br />oar�o <br />.87(3) <br />VAPOR. <br />_, <br />aoo <br />0000 <br />0000 <br />0000 <br />0000- <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />___ <br />000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT 5 LABELED 55 GALLON DRUM 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: �`'-" U Date: 4/3/2012 <br />