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Ce/7 C- Page 1 of 8 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form,written test procedures,and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: SB Gas I Date of Testing: 11/18/08 Facility Address: 515 W. 11th Street, Tracy, CA 95376 Facility Contact: Abdul I Phone: 209-834-2838 Date Local Agency Was Notified of Testing: 11/04/08 Name of Local Agency Inspector(if present during testing): N/A 2. TESTING CONTRACTOR INFORMATION Company Name: EPIC Compliance Systems, Inc. Technician Conducting Test: Keith A. Huston #5262044-UT Credentials: 0 CSLB Licensed Contractor a SWRCB Licensed Tank Tester License Type: A License Number:880430 Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Caldwell Level Change Indicator N/A 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Secondary Piping 87 a] L] Lj Ll LI Ll LI Ll Secondary Piping 91 0 U L) Ll LI LI Ll LI Secondary Piping Diesel o L) L3 El Ll L:1 L3 L3 Annular Reg. o L3 LI LI L3 u Lj LI Annular 91-Diesel 0 L3 Li 0 Lj Lj Ll Ll Sump 87 0 L3 Ll Ll L) L3 L3 LI Sump 91 Lj o Lj J Ll Lj Lj L3 Sump Diesel L) o Li L) U Lj 0 L) UDC 1-2 Ej Lj El U Lj J ❑ Lj UDC 3-4 1] Ll ❑ L3 0 Ll ❑ L3 UDC 5-6 L3 0 U ❑ 0 ❑ Ll L3 UDC 7-8 0 1 0 1 U 1 ❑ U L L) LLJI If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts tated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 11/18/08