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Ut;126L010 SWRCB,January 2002 ENVIRONMENT HEALTH Page of Secondary Contain ment'YeT Q9$ort 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: 76 Date of Testing: 11-3-09 Facility Address: 5611 WATERLOO RD Facility Contact: PAUL Phone: 209-931-2942 Date Local Agency Was Notified of Testing: 10-26-09 Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: SST-Service Station Testing Technician Conducting Test: Heath A.McEver Credentials: C CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: Tank Tester,Technicain License Number: 04-1677 Manufacturer Training Manufacturer Component(s) Date Training Expires INCON TS STS 10-132010 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made 87 ANNULAR X ❑ ❑ 0 0 ❑ 0 ❑ 91/DSL ANNULAR X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 SEC LINE ❑ X ❑ ❑ ❑ 0 ❑ 91 SEC LINE ❑ ❑ X ❑ ❑ 0 ❑ ❑ DSL SEC LINE X ❑ ❑ ❑ ❑ 0 0 ❑ 87 STP SUMP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 STP SUMP ❑ X ❑ ❑ ❑ 0 0 ❑ DSL STP SUMP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISP 1-2 ❑ ❑ X ❑ C 0 ❑ ❑ DISP 3-4 0 ❑ X ❑ ❑ 0 ❑ ❑ DISP 5-6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISP 7-8 X-1 ❑ ❑ ❑ ❑ LE I ❑ I ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OFT HNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the fac fated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: Z"