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JUN-16-2010 09:08 Service Station Systems 408 938 8888 P.03 <br /> s <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use rhe <br /> appropriate pages of this form to report results fur all components tested The completedform, written test procedures,, and <br /> printouts from tests(if applicable), should he provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1, FACILITY INFORMATION <br /> Facility Name: Shell#136186 1 Date of Testing: 6/7/10 <br /> Facility Address: 3725 N Tracy Blvd—Tracy CA95376 <br /> Facility Contact: Phone: <br /> Date Local.Agency Was Notified of'resting: SB989—3yr.Compliance Test <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.05254517-UT Sam Sousa ICC#5254516-UT <br /> Credentials: 14 CSL.B Licensed Contractor J SWRCB Licensed Tank Tester <br /> License Type: A,B,Haz.,C10 License Number. 312844 <br /> Manufacturer Trninin <br /> Manufacturer Component(s) Date'i'rain in Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component: Pass Fail Tested Made Component: Pass Fail Tested Made <br /> Tank Annular(wet annulars) ❑ 0 C1 C187 Fill Sump ® Cl 1387 Secondary Product Q ® ❑ D 89 Fill Sump 0 ❑ ❑ ❑ <br /> 89 Secondary Product ® ❑ ❑ ❑ 91 Fill Sump 0 ❑ 11 <br /> 91 Secondary Product ® ❑ ❑ C] Diesel Fill Sump [1 ❑ ❑ <br /> Diesel Secondary Product ❑ ❑ ❑ 87 Fill bucket ® ❑ ❑ ❑ <br /> 87 Turbine Sump Q ❑ 0 ❑ 89 Fill Bucket ® ❑ ❑ ❑ <br /> 89 Turbine Sump LTJ ❑ ❑ ❑ 91 Fill Bucket ® ❑ 0 0 <br /> 91 Turbine Sump M 0 ❑ p Diesel mill Bucket ® ❑ ❑ ❑ <br /> Diesel Turbine Sump Im 0 ❑ ❑ 87 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 1/2 Ill ❑ ❑ ❑ 89 Vapor Bucket ® 0 ❑ ❑ <br /> UDC 3/4 ® 11110 91 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 5/6 IN ❑ 110 0 0 ❑ 11UDC 7/8 ® 0 ❑ ❑ El 0 0 ❑ <br /> UDC 9/10 ® ❑ a ❑ ❑ Q 0 ❑ <br /> UDC 11/12 ® ❑ ® ❑ ❑ ❑ ❑ ❑ <br /> UDC 13/14 El ❑ ❑ ❑ Cl 0 0 ❑ <br /> UAC 15/16 I ❑ ❑ ❑ <br /> 1 f hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used um test truck <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: 6/7/10 <br />