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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 /> I. FACILITY INFORMATION <br /> Facility Name: SHELL/USA 9 68153 Date of Testing: 1/25/11 <br /> Facility Address; 2448 W.Kettleman Lane–Lodi CA 95242 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of"festing: SB989–3yr.Compliance Test <br /> Name of Local Aganey Inspector(if present during testing): <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.#5254517-CJT <br /> Crcdcntials: ® CSLB Licensed Contractor U SWRCB Licensed Tank Tester <br /> License Type:A,B,If=,CIU Liccnsc Numbcr: 312844 <br /> Manufacturer Training <br /> Manufacturer component(s) Date Trainin&Expires <br /> Available upon request <br /> 3. SUMMARY OF 'TEST RESULTS <br /> Component: Pass Fail Not Repairs Component: Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Tank Annular 0 ❑ ❑ ❑ 87 Fill Bucket R] ❑ ❑ ❑ <br /> 89 Tank Annular 0 [] Q ❑ 89 Fill Bucket ® ❑ ❑ ❑ <br /> 91 Tank Annular ® ❑ ❑ ❑ 91 Fill Bucket ® ❑ ❑ ❑ <br /> 87 Secondary Product ❑ ® ❑ ❑ 87 Vapor Bucket © ❑ ❑ 0 <br /> 89 Secondary Product El ® El [189 Vapor Bucket © El ❑ <br /> 91 Secondary Product ❑ ® ❑ ❑ 91 Vapor Bucket ® ❑ ❑ ❑ <br /> 87 Turbine Sump ❑ ® ❑ ❑ ❑ ❑ [1 [189 Turbine Sump 0 C 11 11 El [I Cl <br /> 91 Turbine Sump ❑ ® ❑ ❑ 0 © ❑ ❑ <br /> UDC 1/2 ® ❑ ❑ 0 0 ❑ 0 ❑ <br /> UDC 3/4 ® ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> UDC 5/6 ® ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> UDC 7/8 W 70M, 0 ❑ ❑ ❑ ❑ Cl <br /> 87 Fill Sump ® Q ❑ ❑ ❑ ❑ I7 ❑ <br /> 89 Fill Sump ® ❑ ❑ ❑ ❑ ❑ 0 0 <br /> 91 Fill Sump © ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pump test truck used for testing <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:—_T— _ _ _ Date: 1/25/11 <br /> Eo'd 8888 826 Bab swa4sRS u01�2-4.S a3TAJ@S ZZ:TT TT0E--2E–Nnf <br />