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SWRCB,January 2002 Page of <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: United Gas I Date of Testing: 7/29/09 <br /> Facility Address: 440 W.Charter Way,Tracy Ca 95378 <br /> Facility Contact: Jodha Gill Phone: 209465-2487 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector('(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC#5252406 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested Repairs <br /> Component Pass Fail Tested Made <br /> UDC 7&8 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 11 <br /> ❑ ❑ ❑ El ❑ 110 <br /> ❑ ❑ ❑ ❑ El El ❑ ❑ <br /> ❑ ❑ ❑ El El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <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 Signa Date: ` �� 7/v <br />