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1�Mall4NCf Page 1 of 8 0///r6VS1EMB 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 forrrr to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Jimco Truck Stop Date of Testing: 05/22/2009 Facility Address: 1022 Frontage Road Ripon, CA 95336 Facility Contact: ]arnail 7 Phone: (209) 599-2111 Date Local Agency Was Notified of Testing: 05/20/2009 Name of Local Agency Inspector(if present during testing): N/A 2. TESTING CONTRACTOR INFORMATION Company Name: EPIC Compliance Systems Technician Conducting Test: Keith Huston Credentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number: 880430 Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Caldwell Level Indicator N/A 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Annular I@ ❑ ❑ ❑ UDC 6S-7S ® ❑ ❑ ❑ Seconds 1 0 ❑ ❑ ❑ UDC 7-8 El ❑ ❑ ❑ Secondary 2 21 ❑ ❑ I ❑ ❑ ❑ ❑ ❑ Secondary 3 ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ Secondary 4 ❑ o ❑ ❑ ❑ o ❑ ❑ Sump 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sump 2 �_ ❑ ❑ Ll El El sump 3 C] 0 ❑ ❑ ❑ ❑ ❑ ❑ Sump 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 1-2 0 ❑ ❑ ❑ ❑ ❑ ❑ Li UDC 3-4 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 5-6 ❑ ❑ ❑ 1 ❑ -2-1 ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Filtered back into 500 gallon water trailer. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 05/22/2009