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MAT'-28-2010 19:52 Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> This <br /> 'form is intended'lbr use by contractors performing periodic testing of US?'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 (f applicable), should be provided to the facility'oivner/operator for.submiltal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: USA Gas f#68153 I Date of Tcsting: 4/30/10 i <br /> Facility Address: 2448 W Kettleman Lane—Lodi CA 95242 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notificd of Testing: SB989— <br /> Name of Local Agcncy Inspector(if present during testing): <br /> 2. TES'T'ING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Tcst: Eledin Sanchez ICC##5313877-UT <br /> Credentials: ® CS1.13 Licensed Contractor -SWRCB Licensed Tank Tester <br /> License'fypc:A,B.Hoz.,C10 License Numbcn 312844 <br /> fManufacturer Training <br /> 4 Manufacturer (:om onent(s) Date TrainingExpires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component: Pass rail Tested Made Component: Pass Nail Tested Made <br /> 87 Fill Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 89 Fill Sump ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Fill Sump D ❑ ❑ i ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ 13. ❑ ❑ ❑ <br /> ❑ ❑ ❑ o a i ❑ ❑ ❑ <br /> c ❑ ❑ C1 ❑ El � <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Cl ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ c o <br /> Cl <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ 11 ❑ Cl ❑ ❑ <br /> Cl ! ❑ ❑ p ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ 0 0 ❑ D ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used pump test truck <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: 4/30/10 <br />