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, <br /> cG�®C <br /> Page I of 8 / <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 appropriate pages of <br /> this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable),should <br /> be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Nicks Shell I Date of Testing: 06/03/08 <br /> Facility Address: 16500 S. Harland Rd., Lathrop, CA 95330 <br /> Facility Contact: Chris Phone: (619) 518-8378 <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: EPIC Compliance Systems <br /> Technician Conducting Test: Masoud Fany & Keith Huston Service Technician#: 5314656-UT <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number:880430 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON INCON TS-STS 12/28/08 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 81 STP Sump 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP Sump 1XI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dis . 1/2 UDC 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dis . 3/4 UDC ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dis . 5/6 UDC 0 D ❑ ❑ D D ❑ D <br /> Dis . 7/8 UDC 0 ❑ ❑ ❑ D D D D <br /> 87 Annular ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Secondary El ❑ ❑ ❑ ❑ ❑ D ❑ <br /> 91 Annular 1XI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Secondary o D D ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Taken with testing technicians. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fa is stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �i Date: 06/03/08 <br />