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� 1f11 �0 U l5L'UJ <br /> e <br /> SWRCB,January 2002 Page_I_of_7_ <br /> Secondary Containment Testing e"`�R0" T HEALTH <br /> This form is intendedfor 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 farm, 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: ARCO#05450 Date of Testing: 5/18/16 <br /> Facility Address: 1617 W FRMONT#1,STOCKTON,CA 95203 <br /> Facility Contact: SARAH SAMUELS I Phone: (360)371-8111 <br /> Date Local Agency Was Notified of Testing: 5116/16 <br /> Name of Local Agency Inspector(f present during testing): NONE PRESENT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br /> Technician Conducting Test: DANIEL SALAS <br /> Credentials: ®CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A License Number:803705 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> ECC CA UST SERVICE TECHNICIAN#5248114-UT 7/30/2017 <br /> FRANKLIN FUELING INCON SUMP TESTER#5248114-UT 9/3/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 MAIN TANK ANNULAR ® ❑ ❑ ❑ UDC#112 ® ❑ ❑ ❑ <br /> 87 MANIFOLD TANK ANNULAR ® ❑ ❑ ❑ UDC#3/4 ❑ ® ❑ ❑ <br /> 91 TANK ANNULAR ® ❑ ❑ ❑ UDC#5/6 ® ❑ ❑ ❑ <br /> 87 MAIN PRODUCT SECONDARY ® ❑ ❑ ® UDC#7/8 ❑ ® ❑ ❑ <br /> 87 MANIFOLD PRODUCT SEC ® ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> 91 PRODUCT SECONDARY ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 MAIN STP SUMP ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 MANIFOLD STP SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 MAIN FILL SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 MANIFOLD FILL SUMP ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 FLL SUMP ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: 5118116 <br />