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FEB-25-2011 15:24 Service Station Systems 408 938 8888 P.02 <br /> a <br /> Secondary Containment 'besting Report Form <br /> This form is intended for use by contractors performing periodic testing of LIST secondary containment systems, U.ye 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 thefacility owner/operatorfor submittal to the local regulatory agency, <br /> 1, FACILITY INFORMATION <br /> Facility Name: USA#68152 1 Date of Testing: 1/26/11 <br /> Facility Address: 401 W,Kettleman Lane—Lodi CA 95240 <br /> Facility Contact: Phone: <br /> Date local Agcney Was Notified of Testing: SB989—3yr.Compliance Test <br /> Name of Local Agency inspector(df present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.05254517-UT <br /> Credentials: ® CSW3 Licensed Contractor u SWRCB Licensed Tank Tester <br /> License'Type:A,B,H=,C10 I Licensc Number: 312844 <br /> EMMINNINNE111191ME111 11 <br /> Manufacturer Training <br /> Manufacturer Compoyi,-ntf C1 Datc Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component: pass Fait rested Made Cumpanent: Foss Fail Tested Made <br /> 87 Tank Annular ® ❑ ❑ © ❑ ❑ ❑ ❑ <br /> 91 Tank Annular ® ❑ ❑ 0 ❑ D ❑ ❑ <br /> 87 Secondary Product ® ❑ ❑ 0 ❑ ❑ 0 ❑ <br /> 91 Secondary Product ® ❑ ❑ ❑ 0 0 ❑ D <br /> 87 Turbine Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Turbine Sump 1 ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> UDC 1/2 ® Co ❑ D d ❑ ❑ ❑ <br /> UDC 3/4 ® ❑ ❑ ❑ ❑ 0 0 ❑ <br /> UDC 5/6 191 ❑ ❑ 0 ❑ ❑ ❑ .❑ <br /> UDC 7/8 ® D ❑ ❑ ❑ 0 ❑ ❑ <br /> 87 Fill Bucket d ❑ ❑ ❑ ❑ 0 ❑ 0 <br /> 91 Fill Bucket Cil 0 ❑ ❑ ❑ ❑ d ❑ <br /> 87 Vapor Bucket ® ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> 91 Vapor Bucket ® ❑ ❑ ❑ 0 0 ❑ ❑ <br /> ❑ n a ❑ ❑ ❑ ❑ Cl <br /> ❑ a ❑ Cl <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pump test truck used for testing <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: 1/26/11 <br />