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JUN-26-2007 16:06 Service Station Systems 14100 7�O 0000 <br />v <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION <br />Facility Name: USA Gas I Date of Testing: 6/12/07 <br />Facility Address: 2132 Mariposa Road — Stockton CA 95205 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: SB999 —3yr. Compliance Test <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Pass Fail Not Repairs Notes: <br />Tested Made <br />Technician Conducting Test: Marc Tillotson / I.C.C. #5252035 -UT <br />Credentials: 0 CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: A, B, Haz, CIO <br />Secondary Pipe - 4 <br />I License Number. 312844 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Ex ires <br />Available upon request <br />UDC - 7 <br />3. SUMMARY OF TEST RESULTS <br />Component: <br />Pass Fail Not Repairs Notes: <br />Tested Made <br />Tank Annular - 4 <br />0 <br />Secondary Pipe - 4 <br />Turbine Sump - 4 <br />UDC - 7 <br />Fill Sump - 4 <br />TLM Sump - 0 <br />Spill Bucket - 8 <br />El 87 vapor bucket failed <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, tke jaets stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: bate: <br />