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'SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containinent 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 /> FacilityName: UNITED GAS Date of Testing: 10/14/2008 <br /> Facility Address: 440 W CHARTER WAY STOCKTON, CA, 95206 <br /> Facility Contact: JADHA GILL Phone: (209) 465-2487 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/17/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Made <br /> Tank Annular 1 REG E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Tank Annular 2 SUP x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 1 REG REG ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 2 SUP SUP ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 REG El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 2 SUP E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 El ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> UDC <br /> UDC 3/4 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 El ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> UDC <br /> UDC 7/8 ❑ P`� l ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El El El El <br /> El- <br /> El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <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: L Date: 10/14/2008 <br />