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S kRCB,January 2002 • • Page 1 of 7 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(cf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name:Anabi Shell Date of Testing:7/6/18 Facility Address:2375 W Grant Line Rd.,Tracy, CA 95377 Facility Contact:Manager Phone: Date Local Agency Was Notified of Testing :6/28/18 Name of Local Agency Inspector(fpresent during testing):Zuna Barker 2. TESTING CONTRACTOR INFORMATION Company Name:Dimaggio Maintenance Technician Conductin Test:Daniel Noone ICCO0261996 Credentials: VFCSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B, Haz License Number: 888681 Manufacturer Training Manufacturer Component(s) Date Training Expires Franklin Fueling Incon STS 7/25/19 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made 87 A Secondary Product �( ❑ ❑ ❑ ❑ ❑ ❑ ❑ 89 A Secondary Product ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 A Secondary Product ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel A Secondary Product ❑ V ❑ ❑ SEP 2.8 2018 ❑ ❑ ❑ ❑ 87 B Secondary Product ❑ ❑ ❑ ❑ ❑ ❑ ❑ 89 B Secondary Product ❑ ❑ ❑ ENVIRONMENTAL HEALTH ❑ ❑ ❑ ❑ 91 B Secondary Product ❑ ❑ ❑ DEPARTMENT ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATI OF TECHNICI RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledg h facktat t s cument are accurate and in full compliance with legal requirements Technician's Signature: Date:7/6/18