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.07/3012009 11:56 FAX 209 744 0116 IA0002/0003 <br /> ' !u1 30 09 09: 0Sa JP P rcleum Service 9163 4873 p. 1 <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report For <br /> This form is iwended for use by contractors performing periodic testing of UST secondary containment systems Use the <br /> appropriate pager of this form to report rewlfs for all components tested The completed form,written test procedures, and <br /> printouts from tests(#"applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACII M INFO TION <br /> Facili Name: Trac Truck S Date of Testin • 7/28/09 <br /> Facility A 3940 N.Tracy Blvd,Tracy Ca <br /> Facility Contact: Debbie/Greg Phone: 209-401-2379 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR O TION <br /> Com Name: JP Petroleum Service <br /> Technician Conducting Test: John Pu mala <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Neunber: 811471 ICC#5252406 <br /> 1Vlamfactarer IMICIn <br /> Manufacturer Component(s) Date TralninExpires <br /> 3. SUMMARY OF.TEST RIESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Line 1 Regular X Q 0 C ❑ ❑ C ❑ <br /> Line 2 Premium x ❑ ❑ ❑ ❑ ❑ G C <br /> Line 3 Diesel x ❑ 1 ❑ ❑ [1 1 ❑ ❑ 01 <br /> ❑ C ❑ ❑ ❑ ❑ ® C <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ C ❑ ❑ ❑ <br /> C ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 3 ❑ Cl ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TRIS TESTING <br /> To the best of my knowledge;thefacts stated In this document are accurate and In full compliance with legal requirements <br /> Technician's Si Date: <br />