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1 <br /> Elite IV Contractors <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors petforming periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of This form to report results for all components tested. The completed form,written test procedures, and <br /> printouts from tests frf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gas Depot I Date of Testing: 01/29/15 <br /> Facility Address: 1330 E.Yosemite Ave,Manteca CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Elite Iv Contractors <br /> Technician Conducting Test: Joe Bartholdi <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number:660076 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Product Line X ❑ ❑ ❑ UDC 9/10 X ❑ ❑ ❑ <br /> 91 Product Line X ❑ ❑ ❑ UDC 11/12 X ❑ ❑ <br /> DIE Product Line X ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> 87 Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DIE STP X ❑ ❑ ❑ <br /> 87 Annular X D ❑ D q. <br /> 91 DIE Split Ann X ❑ ❑ ❑ A 11Q 41 Q 11 Q ❑ <br /> UDC '/z X ❑ ❑ ❑ d1 e U 1h ❑ <br /> UDC '/4 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 X ❑ ❑ ❑ ENT; g <br /> UDC 7/8 X ❑ ❑ ' - ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Filled UDC with water found#1/2, 5/6, 7/8 good, 43/4, 7/8,and 11/12 failed test <br /> and appear to a leaking through conduit penetrations. <br /> CERTIFICATIO OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,t facts fated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 2`1 <br />