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FEB-25-2811 15:35 Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> Thisfnrm is intended for use by contractors performing periodic testing of'UST secondary containment systems. Use the <br /> appropriate pages of this faint to report results,for all components tested. The completed,form, written test procedures, and <br /> printouts from tests ff applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHELL/LSA J#68153 Date of Testing_ 1/25/11 <br /> Facility Address: 2448 W.Kettleman Lane—Lodi CA 95242 <br /> Facility Contact; I Phonc. <br /> Date Local Agency Was Notified of Testing: SB989—3yr.Compliance Test j <br /> Name of Local Agency [nspector(if present duri?2g testing); <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. _ <br /> Technician Conducting Tcst: ,lames Moore/I.C.C.tt5254517-UT - <br /> Credentials: ® CSLB Licensed Contractor -j SWRCB Licensed Tank Tcster <br /> license Type: A, B,Haz.,CIO { License Number: 312844 rr <br /> W1. <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training E,r.2ires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Component. Pass Fail Not Repairs <br /> i Tested Made Tested Made <br /> 87 Tank Annular Q ❑ ❑ ❑ 87 Fill Bucket ® ❑ ❑ <br /> 89Tank Annular ❑ ! ❑ ❑ 89 Fill Bucket ® ❑ ❑ ❑❑ —� <br /> 91 Tank Annular 121 ❑ ❑ ❑ 91 Fill Bucket ® ❑ u I �I <br /> 87 Secondary Product { ❑ 01 ❑ ❑ 87 Vapor Bucket s ❑ ❑ a <br /> 89 Secondary Product ❑ El ❑ ❑ 89 Vapor Bucket ® ❑ ❑ ❑ <br /> 91 Secondary Product j ❑ (T ❑ ❑ 91 Vapor Bucket ® L] ! ❑ ❑ <br /> 87 Turbine Sump ❑ ® ❑ [j- ❑ ❑ ❑ ❑ <br /> 89 Turbine Sump ❑ ® !, 0 ❑ ❑ ❑ ❑ ❑ <br /> 91 Turbine Sump ❑ ® ' ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 ® I-1 i J EJ ❑ ❑ ❑ ❑ <br /> UDC 3/4 ® p ❑ (] ❑ ❑ ❑ ❑ <br /> j UDC 5/6 ® ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> UDC 7/8 L] ❑ ❑ ❑ 0 0 ❑ 0 <br /> 87 Fill Sump ® ❑ ❑ ❑ ❑ ❑ 0 Q <br /> f89 Fill Sump © ! ❑ ❑ ❑ ❑ ❑ E ❑ Q <br /> 91 Fill Sump ® C] ❑ 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pump test truck used for testing w <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE;FOR CONDUCTING THIS TESTING <br /> To the hest of my knowledge,the facts stated in this document tyre accurate and in full compliance with legal requirements <br /> Technician's Si.-nature: Date: 1/25/11 <br />