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FEB-20-2008 09:03 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 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: USA Gas#68153 1 Date of Testing: 1/31108 <br /> Facility Address: 2448 W.Kettleman Lane—Lodi CA 95242 <br /> Facility Contact: I Phone: (209)369-3124 <br /> Date Local Agency Was Notified of Testing; SR989—3yr.Compliance Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Marc Tillotson/I.C.C.#5252035-Ul <br /> Credentials: ® CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,C10 License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Component(s) Bate Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Component: Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Tank Annular p 89 Fill Sump (� <br /> 89 Tank Annular 0 91 Fill Sump <br /> 91 Tank Annular ® 87 Fill Bucket <br /> 87 Secondary Product 0 89 Fill Bucket <br /> 89 Secondary Product 8 91 Fill Bucket <br /> 91 Secondary Product ® 87 Vapor Bucket p <br /> 87 Turbine Sump ® 89 Vapor Bucket <br /> 89 Turbine Sump ® 91 Vapor Bucket <br /> 91 Turbine Sump El <br /> UDC 1/2 0 <br /> UDC 3/4 til <br /> UDC 5/6 0 <br /> UDC 7/8 <br /> 87 Fill Sump <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: <br />