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SWRCB,January 2002 Page_of Secondary Containment Testing Report Form This form is intendedfor use by contractors perfnrming periodic testing of USTsecondary containment systems Use the appropriate pages ofthisform to report results for all components tested. The completedform, written test procedures, and printouts from tests ffapplicable),should be provided to thefacility owner/operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facili Name: SystennTransport7 _— —$ to TK14 Date of Testing: 5-31-11 Facit Address: 707 E.Roth Road,French Camp Ca 95231 Faciliiy Contact: Sam Phone: 209-983-8062 Data Local Agency Was Notified o f Testing Name of Local Agency Inspector(ifpresent duringiesiing): 2. TESTING CONTRACTOR INFORMATION Company Name: JP Petroleum Service Technician Conducting Test: Gabe Garcia Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number. 811471 ICC S 5281582 Maauracturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pon Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Annular I x ❑ ❑ ❑ ❑ ❑ ❑ IJ Line l xLI ❑ U ❑ ❑ Of Line 2 x U ❑ Ll ❑ D n ❑ Line 3 x n ❑ ❑ ❑ ❑ ❑ C; Sump 1 x ❑ U ❑ ❑ ❑ U n UDC 1&2 x ❑ ❑ ❑ IJ J ❑ UDC Sat 1 x Il ❑ ❑ ❑ ❑ ❑ rl UDC Sat 2 x ❑ U ❑ ❑ ❑ ❑ ❑ U ❑ U ❑ ❑ 1 n ❑ 11 ❑ F- ❑ U ❑ 1 ❑ ❑ n u IJ ❑ ❑ ❑ u ❑ ❑ 17 ❑ n ❑ ❑ U If hydrostatic testing was performed,describe what was doue with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To die' est of my knowledge,tite feltstated in�his d `ument are accurate and in full compliance with legal requirements Techni ian's Signature:J/ � Date: