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APR-30-2010 FRI 05: 37 PM P. 029 <br /> �G�®C <br /> Page 1 of 8 <br /> Secondary Containment Vesting Report Form <br /> This torn is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of <br /> this form to report results for all components tested. The completed form, written test procedures,and printouts from tests(if applicable),should <br /> be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name. TraMf Truck Stop Date of Testing: 04/08/2010 <br /> Facility Address: 3940 N TraSf Blvd Tracy, CA 95304 <br /> Facility Contact: Debbie Jutla Phone: 209-832-5006 <br /> Date Local Agency Was Notified of Testing: <br /> dame of Local Agency Inspector(Ypresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems <br /> Technician Conducting Test: Wesley Morrison <br /> Credentials: 0 CSLB Licensed Contractor ❑SWRCS Licensed Tank Tester <br /> License Type: A License Number.880430 <br /> Manufacturer Traininst <br /> Manufacturer Component(s) Date Training E res <br /> Caldwell Caldwell Level Indicator N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Sump #6 ® ❑ ❑ O ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ C2C3C30 L313 ❑ E3 ❑ ❑ <br /> ❑ C3 C3 C3 E3 C3 C3 C3 <br /> E3 O ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ O <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 C3 ❑ <br /> ❑ ❑ ❑ O ❑ a ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ Q <br /> If hydrosta0r,testing was performed,describe what was done with the water after completion letion of tests: <br /> Filtered back into 500 gallons water trailer. _ <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: 0jl08/2010 <br />