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FEB -25-2011 15:46 Service Station Systems 408 938 8888 P.02 0 0 Secondary Containment Testing Report Form ,This form is intended for use by contractors performing periodic testing of LIST secondary containment systems. Use the appropriate pages of this form to report results for all components tested! The completed forth, written test procedures, and printouts,from tests ((f applicable), should be provided to thefacility nwner/operator for submittal to the local regulatory agency, 1. FACILITY INFORMATION Facility Name: SHELUUSA # 68151 1Date of `Costing: 1/27/11 Facility Address: 35 N Cherokee Lane — Lodi CA 95240 Facility Contact: Phone: Date Local Agency was Notified of'I'esting : SB989 —3yr. Compliance Test Name of Local Agency inspector (if present during testing): SUMMARY3. OF TEST -A Component; Pass Fail Not Repairs Tested Made Component: Pass Fait Not Repairs Tested Made 87 Tank Annular ® ❑ ❑ Ca 87 Vapor Bucket ® ❑ 0 ❑ 89 Tank Annular ® ❑ ❑ (❑ 89 Vapor Bucket GS] 0 ❑ ❑ 91 Tank Annular [ ❑ ❑ ❑ 91 Vapor Bucket ® ❑ ❑ ❑ 87 Secondary Product ® I ❑ 1 ❑ 1 ❑ ❑ ❑ 1 ❑ ❑ 89 Secondary Product ® 0 ❑ ❑ ❑ ❑ ❑ Q 91 Secondary Product 0 ® ❑ ❑ ❑ ❑ ❑ ❑ 87 Turbine Sump G] ❑ ❑ ❑ ❑ ❑ ❑ ❑ 89 Turbine Sump 1XI ❑ ❑ ❑ ❑ ❑ Cl ❑ 91 Turbine Sump ❑ 0 ❑ ❑ ❑ ❑ 0 ❑ UDC 1/2 ® Cl ❑ ❑ ❑ ❑ 0 ❑ UDC 3/4 til ❑ ❑ ❑ 0 ❑ ❑ ❑ UDC 5/6 ❑ ❑ ❑ ❑ UDC 7/8 ® ❑ ❑ ❑ ❑ ❑ C ❑ 87 Fill Bucket ® ❑ ❑ ❑ ❑ 0 ❑ 1 ❑ 89 Fill Bucket C14} ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 Fill Bucket Q 1 ❑ ❑ ❑ if hydrostatic testing was performed, describe what was done with the water after completion of tests: Pump test truck used for testing 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: 1/27/11