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Page 1 of 9 r, 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: Gas Depot I Date of Testing: 11/25/08 Facility Address: 1330 E. Yosemite Ave Manteca, CA 95336 Facility Contact: Ricky I Phone: 209-825-0332 Date Local Agency Was Notified of Testing: 11/04/08 Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: EPIC Compliance Systems Technician Conducting Test: Keith Huston Credentials: 0 CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: A License Number:880430 Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Caldwell Change Level Indicator N/A 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Reg Annular M ❑ ❑ ❑ 1/2 UDC 0 ❑ ❑ ❑ Prem Diesel Annular El ❑ ❑ ❑ 3/4 UDC 0 ❑ ❑ ❑ Req Sec Piping El ❑ ❑ ❑ 5/6 UDC El ❑ ❑ ❑ Prem Sec Piping [H] ❑ ❑ ❑ 7/8 UDC 0 ❑ ❑ ❑ Diesel Sec Piping El ❑ ❑ ❑ 9/10 UDC o ❑ ❑ ❑ Reg Piping Sump El ❑ ❑ ❑ 11/12 UDC FX1 ❑ ❑ ❑ Prem Piping Sump El ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Piping Sum 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Reg Fill Sum ❑ [a] ❑ ❑ ❑ ❑ ❑ ❑ Prem Fill Sump 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Fill Sump o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ ❑ 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 stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 11/25/08