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SWRCB,Jamwary 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: HAMMER / 1-5 ARCO Date of Testing: 04/21/2009 <br /> Facility Address: 3250 W HAMMER LANE STOCKTON, CA, 95209 <br /> Facility Contact: WES PARKINSON Phone: (209) 474-9125 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor F—I SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/17/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> ss <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular 3 SUP El ❑ ❑ ❑ Piping Sump 1 REG E ❑ ❑ ❑ <br /> Tank Annular 1 REG x ❑ ❑ ❑ UDC 1/2 ff] ❑ F-1 ❑ <br /> Tank Annular 2 REG ❑ ❑ F] UDC 3/4 ❑ ❑ ❑ <br /> Secondary Pipe 2 REG SIPHON El ❑ ❑ UDC 5/6 ❑ ❑ ❑ <br /> Secondary Pipe 1 REG FRI ❑ ❑ ❑ UDC 7/8 ❑ ❑ ❑ <br /> Secondary Pipe 3 SUP [fl ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 1 REG F ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 3 SUP Fx1 F-1 o ❑ ❑ ❑ El ELI <br /> Piping Sump 2 REG FRI El ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 REG � ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 3 SUP El 1:1 1:1 ❑ ❑ ❑ <br /> Piping Sump 1 REG E El ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <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: 04/21/2009 <br />