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19/25/2009 13:13 2094749151 HAMMER I5 ARCO PAGE 08116 <br /> VR CB January 2002 0 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended or use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriatepages of this font to report results for all components te,led The completed form,written testprocedures, and <br /> pnntouts from tests(:f applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> I.. FACILITY INFORMATION <br /> Facility Name: HAMMER / 1-5 ARCO Date of Testing: 09/11/2009 <br /> Facility Address_ 3250 W HAMMER LANE , STOCKTON, CA, 95209 <br /> Facility Contact: WES PARKINSON Phone: (2 0 9) 474-9125 <br /> Date Local Agency Was Notified ofTesting: <br /> Name of Local Agency Inspector(if present during testing)- <br /> 2. TESTING CONTRACTOR INFORMATION <br /> C0V4nny Name: TANIWOLOGY, INC. <br /> Technician Conducting Tom; JARROD COOKS <br /> Credentials; ❑CSLB Licensed Contractor � SWRCB Licensed Tank Tester <br /> License Type: a License Nmnber: 743160 <br /> Manufacturer jraining <br /> Manufacturer Corxvorkerrb(s) Date Training Expires <br /> tanknology all 07/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs blot Rept <br /> Component Pass Fail Tested Made Co Hent P F20 Tes <br /> Tank Annular 2 REG ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑I ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 01 ❑ ❑ I ❑ <br /> ❑ I ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 10 El El El❑ . ® ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ El ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water alter completion of tests_ <br /> ma <br /> CERTIFICATION OF TECEMCL4N RESPONSOLE 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 /> Techniciae's S true: Date: 09/11/2009 <br />