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SWRCB,January 2002 Page I of 7 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Express Market Date of Testing: April 24,2009 Facility Address: 419 S.Main St.Manteca,Ca Facility Contact: Kuljit Mangat(Bobby) Phone: 209-239-0700 Date Local Agency Was Notified of Testing: April 23,2009 Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: MVP Petroleum Engineering, Inc. Technician Conducting Test: Jonathan Wolff Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A/Haz License Number:768938 Manufacturer Training Manufacturer Component(s) Date Training Expires ICC California UST Service Technician May 1,2009 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Tank annulars ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping secondary ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ New UDC ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel piping sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this d ument are accurate and in full compliance with legal requirements Technician's Signature: Date: