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Elite IV Contractors 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(f 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: 01/29/15 Facility Address: 1330 E. Yosemite Ave, Manteca CA Facility Contact: Phone: 31 M1 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(if present during testing): '',V11 A Y 2. TESTING CONTRACTOR INFORMATION Company Name: Elite Iv Contractors Technician Conducting Test: Joe Bartholdi E N V i a - - Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number:660076 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made 87 Product Line X ❑ ❑ ❑ UDC 9/10 X ❑ ❑ ❑ 91 Product Line X ❑ ❑ ❑ UDC 11/12 X ❑ ❑ DIE Product Line X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 STP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ DIE STP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 Annular X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 DIE Split Ann X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC '/2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 3/4 X ❑ ❑ ❑ ❑ ❑ ❑ UDC 5/6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 7/8 LA0 El Ll 11 El If hydrostatic testing was performed,describe what was done with the water after completion of tests: Filled UDC with water found#1/2, 5/6, 7/8 good, #3/4, 7/8, and 11/12 failed test and appear to a leaking through conduit penetrations. CERTIFICATIO OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,t facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: