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..i �/P/C <br /> Page I of 8 <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 appropriate pages of <br /> this form to report results for all components tested. The completed form, written test procedures,and printouts from tests(if applicable),should <br /> be provided to the facility ownedoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quickie Kleen I Date of Testing: 10/21/2009 <br /> Facility Address: 707 E Yosemite Avenue Manteca, CA 95336 <br /> Facility Contact: Francene Escobar Phone: 209-814-6274 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(d present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Com fiance Systems <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number:880430 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date TrainingEx ires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular o ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Regular 1 Sump ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> Regular 2 Sump ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> Diesel Sump 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Re ular 1 2ntl pipjing 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Regular 2 2n0 Piping ❑ 0 ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> Diesel 2n' Piping o ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> UDC 1/ 2 ® ❑ ❑ ❑ ❑ ❑ ❑ L3UDC 3/ 4 ® ❑ 13 ❑ ❑ ❑ ❑ <br /> UDC 5/ 6 ® C3 L3 L3 ❑ ❑ ❑ <br /> UDC 7/ 8 ❑ ® C3 L03 ❑ ❑ C3 <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, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 10/21/2009 <br />