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SWRCB, January 2002 0 Page _1_ of —8– AIN 10 X01: Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary conte /' t1 tj(E appropriate pages of this form to report results for all components tested. The completed form, wrill-ft-(e ri and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: ARCO #05450 1 Date of Testing: 5/20/13 Facility Address: 1617 W FREMONT, STOCKTON, CA 95203 Facility Contact: SARAH SAMUELS I Phone: (714) 228-6402 Date Local Agency Was Notified of Testing: 4/30/13 Name of Local Agency Inspector ('(present during testing): NONE PRESENT 2. TESTING CONTRACTOR INFORMATION Company Name: TANK-TEK ENVIRONMENTAL CORP. Technician Conducting Test: DANIEL SALAS Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A License Number: 803705 Manufacturer Training Manufacturer Component(s)) Date Training Expires ICC CA UST SERVICE TECHNICIAN #5248114 -UT 9/6/2013 FRANKLIN FUELING INCON SUMP TESTER #5248114 -UT 9/19/2013 Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made 87 MAIN TANK ANNULAR ® ❑ ❑ ❑ UDC #1/2 ® ❑ ❑ ❑ 87 SYPHON TANK ANNULAR ® ❑ ❑ ❑ UDC #3/4 ® ❑ ❑ ❑ 91 TANK ANNULAR ® ❑ ❑ ❑ UDC #5/6 ® ❑ ❑ ❑ 87 MAIN PRODUCT SECONDARY ® ❑ ❑ ❑ UDC #7/8 ® ❑ ❑ ❑ 87 SYPHON PRODUCT SEC ® ❑ ❑ ❑ 87 MAIN FILL BUCKET ® ❑ ❑ ❑ 91 PRODUCT SECONDARY ® ❑ ❑ ❑ 87 MAIN VAPOR BUCKET ® ❑ ❑ ❑ 87 MAIN STP SUMP ❑ ® ❑ ❑ 87 SYPHON FILL BUCKET ® ❑ ❑ ❑ 87 SYPHON PIPING SUMP ® ❑ ❑ ❑ 87 SYPHON VAPOR BUCKET ® ❑ ❑ ❑ 91 STP SUMP ® ❑ ❑ ❑ 91 FILL BUCKET ® ❑ ❑ ❑ 87 MAIN FILL SUMP ® ❑ ❑ ❑ 91 VAPOR BUCKET ® ❑ ❑ ❑ 87 SYPHON FILL SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 FILL SUMP ® ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: LEFT 6 LABELED 55 GALLON DRUMS ON SITE FOR LATER PICK UP CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 5/20/13