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• <br />Page <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ag <br />1. FACILITY INFORMATION <br />Facility Name: I-5 Shell g: 4-20-2012 <br />Facility Address: 717 West 8'h Street Stockton <br />Facility Contact: Joe Dangtran P e: 009 <br />Date Local Agency Was Notified of Testing: 4-17-12 <br />Name of Local Agency Inspector (if present during testing): v►'a <br />19 1Vr0gr1rXTd1 r1-%rrr1D A r -r"" T?,JVf%RM A "nV <br />of <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Aneil Chand <br />ICC # 5119959 UT <br />Credentials: ❑ Licensed Contractor <br />XLicensed Tank Tester <br />License Type: <br />License Number: SWRB 90-1262 Z 3 <br />Manufacturer <br />Manufacturer Training <br />Com onent(s) Date Training Expires <br />Caldwell <br />Level Change Indicator n/a <br />A CiTMMARV nV TFCT RF.SiTT,T.9 <br />Component <br />Premium <br />-1 <br />���0 <br />' <br />�� <br />/1 <br />Unleaded fill sump <br />i UDC 3-4 sump <br />F"AlPremium <br />fill sump <br />►� <br />o��r■� <br />►i <br />�L70Diesel <br />fill sump <br />/ <br />������ <br />� • � <br />-1 <br />�■ <br />L70 <br />U�L�O <br />• <br />►1 <br />Premiumsecondary-1 <br />���; <br />�� <br />■00■ <br />Diesel secondary line <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: ' -- ate: 4-20-2012 <br />