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APR-30-2008 10:08 Service Station Systems 408 938 8888 P.03 <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 fonn, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the_faciltry owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: USA Gas 468153 j Date of Testing: 4/3/08 <br /> Facility Address: 2448 W.Kettleman Lane—Lodi CA 95242 <br /> Facility Contact I Phone.. <br /> Date Local Agency Was Notified ol-Testing: SB989—Repair/Retest <br /> Name of Local Agency Inspector(if present during resting): <br /> 2 TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: Mike Trejo#ICC 5252033-UT <br /> Credentials: ® CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A,B,Haz.,C10 License Number 312844 <br /> Manufacturer Training <br /> Manufacturer Com oncnt(s) Date Training Expire,, <br /> Available upon request i <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component: Pass Fail Tested MadeComponent: Pass Fail Tested Made <br /> 87 Fill Sump <br /> i <br /> i <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water from test truck was used. <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: <br />