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Page 1 of _8_ <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 agency. <br />1. FACILITY INFORMATION <br />Facility Name: I-5 Shell Date of Testing: 4-30-2012 <br />Facility Address: 717 West 8`s Street Stockton <br />Facility Contact: Joe Dangtran Phone: (408)666-0009 <br />Date Local Agency Was Notified of Testing: 4-28-12 <br />Name of Local Agency Inspector (if present during testing): n/a <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Pinnacle Fuel Compliance Services, Inc. <br />Technician Conducting Test: Ancil Chand ICC # 5119959 UT <br />Credentials: ❑ Licensed Contractor XLicensed Tank Tester <br />License Type: License Number: SWRB 90-1262 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Level Change Indicator n/a <br />3. SUMMARY OF TEST RESULTS <br />PAGE -1 <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: 4-30-2012 <br />Unleaded STP Sump►1 <br />X00'Unleaded <br />Annular <br />��■ <br />�� <br />Q <br />1 • - <br />11 <br />■00� <br />Premium��■ <br />11 <br />0� <br />Diesel/1 <br />M <br />■ODI <br />D <br />0■ <br />11 <br />�00Unleaded <br />fill sump11 <br />�0■ <br />Q, <br />/1 <br />�DOI <br />Premium fill sump <br />11 <br />�■ <br />00■ <br />IFF <br />/1 <br />UL70■ <br />I <br />►1 <br />UC��■7 <br />sit►1 <br />�■ <br />U0� <br />C <br />►1 <br />■00■ <br />�■ <br />�■ <br />0� <br />UDC 11-12 sump <br />►1 <br />X00■ <br />����Oj <br />Unleadedsecond. <br />►1 <br />�00■ <br />��■ <br />00■Premium <br />secondarylineONDiesel <br />secondary line <br />PAGE -1 <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: 4-30-2012 <br />