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f <br /> rnc+sxwca <br /> Pagel 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: California Stop Date of Testing: 10/12/2011 <br /> Facility Address: 2224 Manthey Road, Stockton, CA 95026 <br /> Facility Contact: Timmy Le Phone:209-406-1484 <br /> Date Local Agency Was Notified of Testing: 9/21/2011 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems Inc. <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 956593 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank 1 Annular 0 ❑ ❑ ❑ 7 / 8 UDC z ❑ ❑ ❑ <br /> Tank 2 Annular 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Tank 3 Annular z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Secondary Piping z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Secondary Piping r1_1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Secondary Piping 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Piping Sump ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Piping Sump z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Piping Sump Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 / 2 UDC 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 3 / 4 UDC 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 / 6 UDC D ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Returned to water trailer. <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: 10/12/2011 <br />