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04W& Page 1 of c �-�Fj Secondary Containment Testing Report Form�Nyly ,,Qi,,N�� gwICES PEF,m i I�- 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. FACILITY INFORMATION Facility Name: Kwik Serve I Date of Testing: 05/02/08 Facility Address: 950 W. 11th St., Tracy, CA 95376 Facility Contact: Patel Phone: (209) 832-1810 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: EPIC Compliance Systems, Inc. Technician Conducting Test: Keith A. Huston #5262044 -UT Credentials: 0 CSLB Licensed Contractor L SWRCB Licensed Tank Tester License Type: A License Number: 880430 Manufacturer Traininq Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Super Annular o Ll Ll J 7/8 UDC 0 Ll U Ll Regular Annular o Ll Lj J J 0 J Ll Diesel Annular IF] J J U Lj Li Lj Lj Super Sec. Piping o J J L] Ll Ll Ll Ll Regular Sec. Piping o Ll L3 Q J U 0 LJ Diesel Sec. Piping 0 J Lj Ll Ll Ll Ll J Regular Sump 0 0 Ll J Lj Ll Li Ll Super Sump 1E Ll Ll J j Li Lj Lj Diesel Sump o J Lj L3 LJ Lj Ll Ll 1/2 UDC El J J LJ Ll Lj El ❑ 3/4 UDC 0 ❑ U ❑ ❑ ❑ ❑ D 5/6 UDC IRI J L] ❑ Ll Ll L3 LI 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, thqJf4yts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 05/02/08