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SWRCB, January 2002 to <br />so 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 (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: ARCO #05450, CC 18022647 <br />DateofTesting: 09/24/2009 <br />Facility Address: 1617 W. FREMONT , STOCKTON, CA, 95205 <br />Facility Contact: DEALER/MANAGER <br />Phone: (2 0 9) 462-1617 <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: JOEY MESA <br />Credentials: <br />❑ <br />CSLB Licensed Contractor <br />❑ <br />SWRCB Licensed Tank Tester <br />Spill Box 1 REG FILL <br />License Type: ICC SERVICE TECH. License Number: 5259458 -UT <br />Manufacturer Training <br />Manufacturer Component(s) <br />Date Training Expires <br />OPW SPILL BUCKET <br />12/18/2010 <br />Spill Box 2 REG FILL <br />Component <br />Spill Box 1 REG FILL <br />Spill Box 2 REG FILL <br />Spill Box 3 PRE FILL <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT IN WASTE DRUM ONSITE. <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: 11<� Date: 09/24/2009 <br />