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!. 1 . '1►. R-1 r 11:�91 � W E 0 JUN 2 2008 0&e/`�c Page 1 of 8 P v i -.',l ,ti;EyT HEALTH Secondary Containment Testing Report �� .�; -/SERVICES This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, 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: Al Gas & Food I Date of Testing: 05/15/08 Facility Address: 574 W. Grantline Rd., Tracy, CA 95376 Facility Contact: Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): Michelle Henry 2. TESTING CONTRACTOR INFORMATION Company NoTe: EPIC Ccmpllance Systerns Pass Technician Conducting Test: Masoud Fany Service Techniciank 0878949 -UT Credentials: 21 CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: A Manufacturer License Number: 880430 Manufacturer Training Component(s) Date Training Expires INCON STS Sump Tester 12/28/09 o ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Dispenser 1/2 UDC o ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser 3/4 UDC ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser 5/6 UDC ❑ EI ❑ ❑ ❑ ❑ ❑ ❑ Dispenser 7/8 UDC EI ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ L3 U CI ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Taken away with testing technician. 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: 05/15/08