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0 <br />Pa� -, of —9– <br />Secondary Containment Testing Report Form i <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Us, the <br />The form, written test proceduf es, and <br />appropriate pages of this form to report results for all components tested. completed <br />be to the facility ownerloperatorfor submittal to the local regul4tory agency. <br />printouts from tests (if applicable), should provided <br />1. FACILITY INFORMATION <br />Component 1 <br />Facility Name: 1-5 Shell I Date of Testing: 4-30 1 2015 <br />Facility Address: 717 West 8"' Street Stockton <br />Facility Contact: Joe DangtranPhone: (408)666-0009 <br />Date Local Agency Was Notified of Testing: 4-27-2015 <br />DateLocal <br />�ofl Agency Inspector (if present during testing): n/a <br />_ <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Anefl Chand ICC # 5119959 UT <br />Credentials: 0 Licensed Contractor X Licensed Tank Tester <br />N 90-1262 <br />b r: S <br />License Type: License umeWRB <br />Manufacturer Comvonent(s) Date Tr ing Expire, <br />Caldwell Level Change Indicator Dece er 2017 <br />PAGE -1 <br />CERTIFICATION OF TECHNICIAN RES PONSIEBLE FOR CONDUCTING THIS TESTIP <br />To the best of my knowledge, the facts stated in this document are "curate and in full compliance with legal <br />Date: 4-30-2015 <br />Technician's Signature: <br />re <br />Componnt <br />.. <br />.,. <br />Component 1 <br />le e TP Sum <br />Unleaded Annular <br />i STP Su <br />Premium Annular <br />Diesel STP Sump <br />GO <br />M <br />i Diesel Annular <br />0241 <br />UDC 1-2 p <br />M <br />Unleaded fill sum]) <br />_�um <br />U DC 3-4 _Lump <br />Premium fill <br />sum"_ <br />!'UDC 5-6 <br />Diesel fill Sump <br />UDC 7-8 sump <br />FABI <br />M <br />1 Vellt SUM <br />0 Val <br />0 <br />UDC 9-10 su Lrip <br />Unleaded <br />line <br />Premium secondary <br />line <br />Ems m <br />Diesel second�g <br />line <br />PAGE -1 <br />CERTIFICATION OF TECHNICIAN RES PONSIEBLE FOR CONDUCTING THIS TESTIP <br />To the best of my knowledge, the facts stated in this document are "curate and in full compliance with legal <br />Date: 4-30-2015 <br />Technician's Signature: <br />